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NATURE AND TREATMENT

OF THE

DEFORMITIES OF THE HUMAN FRAME:

BEING A COURSE OF LECTURES

DELIVERED AT THE ROYAL ORTHOPEDIC HOSPITAL IN 1843:

UPttjf nmvmm litotes attif JUi&ittims

TO THE PRESENT TIME.

By W. J. LITTLE, M.D.

LICENTIATE OF THE ROYAL COLLEGE OF PHYSICIANS ; LECTURER ON THE PRACTICE OF MEDICINE
AT, AND PHYSICIAN TO, THE LONDON HOSPITAL ; PHYSICIAN TO THE INFANT ORPHAN
ASYLUM, WANSTEAD ; FELLOW OF THE ROYAL MEDICAL AND CHIRURGICAL

SOCIETY ; MEMBER OF THE PROVINCIAL MEDICAL AND SURGICAL ^ 7 V -

ASSOCIATION, OF THE HUNTERIAN, AND PATHOLOGICAL ^ V — ' *

OF THE SOCIETA MEDICO-FISICA
)F FLORENCE; FOUNDER OF THE ROYAL "

ORTHOPEDIC HOSPITAL; ETC. .-7.

ILLUSTRATED BY UPWARDS OF 160 ENGRAVINGS A

LONDON:

LONGMAN, BROWN, GREEN, AND LONGMANS.

TO HIS

MEDICAL AND SURGICAL BRETHREN,

GRATEFUL ACKNOWLEDGMENT OF THEIR KIND APPRECIATION OF HIS

ENDEAVOURS TO PROMOTE THE DIFFUSION OF

A PRACTICAL KNOWLEDGE OF THE TREATMENT OF DEFORMITIES,

THIS BOOK IS INSCRIBED

THE AUTHOR.

PEERAGE.

Pourteen years have elapsed since tlie author’s
Treatise on the Nature cmd Treatment of Club¬
foot and analogous Distortions with cmd without
Surgical Operationf appeared; from which, period
sub-cntaneous tenotomy has been generally re¬
ceived by the profession as an important addition
to the resources of practical medicine.

An impulse was thus given to the reception
in this country of Stromeyer’s discovery! similar

* The first monograph published on this subject after the in¬
vention of sub-cutaneous tenotomy.

t In France, and amongst some English surgeons who have
followed French writers, it has become the fashion to attribute to
Delpech the discovery of sub-cutaneous tenotomy. The mistake
is perhaps pardonable to our neighbours, who, in the confidence
which great national claims in respect of surgery produces, do
not appreciate the influence of German surgery upon their own
practice; but it is inexcusable in English writers, who, in a
question of science, are bound to take wider views. Between
the times of Thilenius and Stromeyer no actual advance was
made. Stromeyer alone discovered and first practised sub-cutaneous
tenotomy, which is the only absolutely safe mode of operation.

PREFACE.

viii

to that which had been communicated throughout
Germany by the dissemination of the author’s ob¬
servations and personal experience* of the method
three years before in Berlin, and Dieffenbach’s
energetic adoption of it in that city.

In 1843-4 the following Lectures were pub¬
lished in the Lancet, which, as a contribution to
the increasing desire of the profession to become
practically acquainted with the pathology of de¬
formities, the author regarded as a second edition
of the treatise above mentioned. The desire to
secure for these Lectures a more permanent po¬
sition in medical literature, and to take date, as
it were, for whatever of useful or original they
may contain, has induced the author to republish
them, and to interweave the results of ten years’
additional experience. The Lectures are therefore
reprinted with only verbal alterations, except where
indicated; the new matter introduced into the
text is enclosed between brackets; and the notes,
the whole of which are new, appear at the bottom

Delpech had proposed to improve the operation of tenotomy ; but
his proposed improvements did not embrace sub-cutaneous section.
They doubtless suggested to Stromeyer “ materials for thinking.”
See Introduction to Treatise on Club-foot, &c. by the author.

* See the author’s case of non-congenital equino-varus de¬
tailed in Stromeyer’s Beitrage zur operativen Orthopadik.

DEFORMITIES OF THE HUMAN FRAME.

LECTURE I.

Introductory lecture — Importance of the study of deformities to medical
students—Deformities not neglected by the ancients—More recent
attention to the subject—Discovery of subcutaneous tenotomy by Stro-
meyer—Interest of the study of pathology of deformities—External
resemblance of distortions produced before and after birth—Similarity
of producing causes—-Classification of deformities.

In commencing a series of lectures on the deformities of
the human frame, I shall briefly allude to the circumstances
which have occasioned their delivery. The charitable insti¬
tution in which we are now assembled was founded in 1838,
less than two years after the introduction into the metro¬
polis of Stromeyer’s improved method of remedying, by
subcutaneous section of tendons, the deformity named club¬
foot. The principal reasons assigned by the supporters of
the charity for establishing an additional medical eleemo¬
synary institution in London, were the dispensation of that
relief to poor persons afflicted with deformities which they
were unable to obtain in the existing hospitals, the forma¬
tion of a school for studying deformities, and instruction in
the art of remedying them. Difficulties in forming the
charity were not unforeseen. For my part, I was con¬
vinced that the best method of overcoming such prejudices
as exist in the profession against the establishment of
charities for treating special branches of medicine, would

INTRODUCTORY LECTURE.

consist in freely inviting its members to witness our pro¬
ceedings and share its benefits. Our wards have, in con¬
sequence, been numerously visited by physicians and sur¬
geons from all parts of the kingdom, and by many eminent
foreigners. My own reward for assisting to form this insti¬
tution has consisted in the resulting professional intercourse
with so many enlightened individuals, in the many opportu¬
nities of investigating distortions of the frame here afforded
me, and in the gratification experienced in delivering these
lectures, and in acquainting you with the information that
I have thus been enabled to 'acquire on the subject. The
charity already presents to you a large field for observation.
The average number of out-patients in almost daily attend¬
ance is upwards of fifty. Among them you may witness
every deformity that occurs, principally in infants and chil¬
dren ; while the more severe cases, usually those of adults,
are admitted into the wards, where ten or twelve beds are
generally occupied,—a number of patients amply sufficient
for clinical purposes. I therefore hope that the medical
students of London will, by attending a month or longer
on this branch of practice, derive advantages that were not
possessed by their predecessors. Deformities are not less
interesting to them ‘than diseases of the eye. Students,
when in practice, will probably find equally numerous
occasions of relieving congenital or acquired deformities
as of curing affections of vision; and since attendance on
an ophthalmic infirmary is justly considered essential to
the completion of a medical education, so, in my opinion,
students who, in the present day, leave the metropolis with¬
out adequate acquaintance with the treatment of defor¬
mities, will by and by lament the omission.*

Although the importance of studying the treatment of
deformities has recently been more fully acknowledged, it

* The necessity for this attention to the study of the nature and treatment
of deformities by at least the younger members of the profession, as a part of
their daily duty, is further illustrated by the large number of applicants to the

INTRODUCTORY LECTURE.

was not neglected by the ancients: it was not omitted by
Hippocrates, who shewed a correct acquaintance with club¬
foot in his treatise On Articulations and his method of re¬
storing an infantile deformity of this nature by bandaging,
may be advantageously followed, in an appropriate case,
in the present day. In truth, the methods of remedying
infantile club-foot related by succeeding authors are but
different versions of the precepts of the father of medicine.
Several treatises on the cure of special deformities, or
on malformations in general, were published during the
eighteenth century, though few of them are entitled to
rank as scientific works. At that period the art became a
special branch of healing, and upwards of a hundred years
since it received the title of the Art of Orthopaedy.

With improvements in medicine generally, increased
attention was given to deformities, particularly to congeni¬
tal malformations; the radical cure of hare-lip, described
by Celsus and the Arabians, became a common operation;
other congenital fissures were restored by the plastic art ;
and the division of the sterno-mastoideus muscle, for the
cure of wry-neck, was frequently effected by distinguished
surgeons.

The uncertainty, the difficulty, and the frequent impos¬
sibility of curing many deformities, caused orthopaedy to
be relinquished by the regular surgeon to empirical prac¬
titioners entirely destitute of medical knowledge. Hence,
even after the commencement of the present century, the

existing Orthopaedic Hospitals in Bloomsbury Square, Hatton Garden, and
Portland Road, who cannot be received into those establishments through
inadequacy of space and funds. At the present moment (1852) hundreds daily
receive relief as out-patients, and about fifty beds are constantly occupied by
in-patients, free of expense to the sufferers. These facts strongly plead both
the necessity of further pecuniary support to these charities, or the acquire¬
ment, by the bulk of the profession, of such an experience of the treatment of
distortions as may discourage the over-ready applications to charities by those
whose position in life, being above pauperism, should render them ineligible
for eleemosynary aid.

FORMER ABANDONMENT

treatment of deformities remained for the most part in per¬
fectly ignorant hands. So neglected in general was the
matter, that an unfortunate sufferer from a congenital de¬
formity, after failure of some simple means adopted by
the midwife or accoucheur, was happy, in many situations,
in finding a common blacksmith who could partially relieve
his infirmity by the construction of “ an iron.” Individual
empirics and instrument-makers, b} T dint of greater per¬
severance, unquestionably obtained greater success in treat¬
ment than others; but their experience was either confined
to themselves, being totally lost on the cessation of their
labours, or, if they published any account of them, the
work consisted usually only of announcements of their
“remarkable cures,” instead of the means by which other
practitioners might reasonably expect success. A circum¬
stance equally prejudicial to the art of curing deformities
was the common habit of exaggerating the results of any
really useful plan, less, in many instances, from studied
dissimulation, than from the tendency to delusion in the
empiric, who had, in truth, occasionally effected a cure
that had not been attempted by a regular practitioner.
Success in some cases created a greater evil, namely, that
of professing to remedy more serious deformities. Failure
in these brought discredit on preceding labours, and so
retarded confidence in orthopaedy. Thus the labours of
the few talented medical men who devoted their energies
to this subject did not receive proper attention. The
names that stand foremost among the regenerators of or¬
thopaedy are those of Thilenius, a physician of Frankfort,
who first [about 1789] caused division of a contracted tendo
Achillis to be effected; of Scarpa,who first [1808] attempted
the scientific adaptation of an apparatus to the anatomical
condition of the bones of the distorted foot; of Michaelis
[1811] and Sartorius, who repeated the operation of Thi¬
lenius ; of Dupuytren, who investigated the pathology of
contracture of the fingers, and improved the operation for

OF DEFORMITIES TO MECHANICS.

wry-neck ;* and of Delpech [1823-29], who perceived the
cause of previous failure, hut who omitted to act on the
principles he had adopted. The labours of Delpech, though
calculated to arouse the attention of surgeons, remained
apparently unheeded until they evoked the talents and ar¬
dour of Stromeyer [1830], to whom is due the discovery
of subcutaneous tenotomy,f its application to club-foot, and
its establishment as a principle in operative medicine.

An immense and rapid advance in the treatment of de¬
formities has taken place since Stromeyer demonstrated
the absolute safety of this mode of operation. The at¬
tempt to cure deformities is no longer disdained by medical
men of eminence. Many of my own students have diffused
the methods here practised in the majority of the British
colonies and in some foreign states. Every month has in¬
creased the usefulness of the practical orthopaedist. Teno¬
tomy has now been successfully applied to every part of
the frame [from which has resulted its indiscriminate use
by some too sanguine practitioners]. Without exaggeration
it may he stated, that at the present moment many of the
most unsightly deformities can be cured with less incon¬
venience than any other class of afflictions at all compa¬
rable with deformities in the bodily and mental suffering
they occasion. This improvement is attributable to in¬
creased experience in the mechanical treatment. Notwith¬
standing the prevalence of belief in the beneficial effects
of proper treatment in relieving deformities, few practi¬
tioners are aware that such distortions as these (shewing
them ) can be so nearly approximated to symmetrical con¬
formation as the models placed upon the table. The success
which may now attend the treatment of deformities, and
the extreme frequency of such malformations, should ob-

* Sir A. Cooper operated for contracted finger from diseased plantar
fascia. He was unacquainted with subcutaneous tenotomy, and attempted to
denude and remove the diseased parts by crucial incision and dissection.

t From revtov, tendon, and re/J-vetu, to cut.

PATHOLOGY OF DEFORMITIES.

tain for the subject great attention amongst medical men.
Moreover, it is not a dry subject, interesting merely as a
branch of practice. The varieties, the etiology, and the
pathology of deformities involve questions of the utmost
interest to physiologists. The various abnormal forms of
the human frame, and the manner of their production, are
calculated to illustrate some obscure points in the nervous
system. Here are four casts of talipes varus , each pre¬
cisely [closely] resembling its neighbour in form, yet each
has been preceded by different etiological and pathological
events. Here is a similar series of the deformity, named
talipes equinus, and there a similar collection of talipes
valgus. Here is a model of a congenital deformity of
numerous articulations, and there is one of a series of de¬
formities occurring after birth, so entirely resembling the
congenital case, that at first sight they appear to be iden¬
tical. The study of the causes of changes that in form
are so similar, their pathological analogies, and the pro¬
bability and degree of their restoration, affords a new
field of inquiry. Orthopaedy is something better than
a mere mechanical art; whilst employing its therapeutic
resources, many of which are mechanical, the mind is also
interested in problems that have hitherto been incompletely
solved. In these lectures, however, I shall not tread the
paths of theory and speculation, but keep strictly within
the limits of practical utility.

The course is designed for students, and from the small
number of lectures of which it will consist, must be con¬
fined principally to elementary and practical matters, be¬
coming, in fact, a series of demonstrations of the subjects
rather than formal lectures. As to the manner in which
the subjects can be subdivided for the best comprehen¬
sion. of my views on the pathology and treatment of distor¬
tions, a topographical arrangement [in the usual manner
of authors] would appear at first view to be the most
simple. Thus I might commence with deformities of the

MODES OF ARRANGING DEFORMITIES.

head and neck, and proceed seriatim to those of the hip,
the knee, the ankle, &c.; but although simple, that plan
would be too mechanical to diffuse much light on the
pathology of the subject, besides occasioning many re¬
petitions and confusion of the subject. An anatomical
subdivision would be the most complete. Thus I might
consider, first, the deformities arising from diseases of
the bones; secondly, those resulting from diseases of the
muscular system; thirdly, those arising from diseases of
the ligaments; and in this manner successively review the
influence of disease of the several tissues in producing
deformity. But although this proceeding would offer the
best guarantee of certainty and accuracy, I am doubtful
whether the morbid anatomy of deformities has hitherto
sufficiently progressed to enable me thus to classify these
affections.* Besides this objection, you will find, on ad¬
vancing in the study of distortions, that derangements of
the osseous and muscular systems are so frequently com¬
bined as to render a strictly anatomical arrangement im¬
possible.

In the present state of the science, therefore, I prefer
a classification that is allied to the anatomical , namely, one
founded on the pathology of deformities. It will, at one
view, be found more suggestive of information relating to
their nature; for although the etiology and pathology of
some distortions is still involved in a degree of obscurity,
inaccuracies are less liable to occur in referring them to
pathological heads. Numerous deformities are congenital,
a still larger number are acquired or developed after birth.
Perhaps you will consider that congenital distortions should
give to them a claim to prior consideration; and, indeed,
the mystery attached to their origin has long almost ex¬
clusively attracted the investigation of distinguished ana¬
tomists and physicians. Popular emotion has at all times

* Nearly ten years have elapsed since the above was published. A work is
announced in the press from the able hands of Mr. Lonsdale, in which he
proposes to adopt the anatomical arrangement.

EXCITING CAUSES OF DISTORTION.

been powerfully excited by tbe view of congenital deformi¬
ties, and they have been speedily brought to the notice of
professional men; this affords an additional explanation
why more frequent attempts at restoration have been made
of these than of acquired distortions. But, in my opinion,
if the non-congenital deformities had previously arrested
their inquiries, they would, by studying the production of
that which daily occurs to view, have more readily and
correctly comprehended the origin of that which occurs
secretly in the uterus. I shall commence with acquired
deformities, believing that when conversant with these
you will better understand the nature of congenital affec¬
tions.

A constantly recurring cause of deformity is inflamma¬
tion and disease of an articulation. The surgeon views
with apprehension the progress of such a case, often pro¬
ceeding, as it does, in defiance of every remedial measure.
He witnesses the production of a contracted and immov¬
able articulation; or even greater disorganisation of the
ligaments and other tissues of the articulation having
ensued, most serious deformity results. The pathological
changes that have produced deformity are in those in¬
stances perfectly understood. Their progress being often
slow, they can be conveniently studied and their respective
influences determined. Hence th e first subdivision of non-
congenital deformities which I shall consider consists of
those arising from causes directly affecting the articula¬
tions. This subdivision includes, therefore, the contrac¬
tions induced by injuries or diseases of articulations,—all
the various forms of stiff-joint, or ankylosis, the causes of
which act primarily on the passive organs of movement,
namely, the joints.

An equally numerous series of deformities results from
causes which operate indirectly on the articulations. For
instance, spasmodic affections of the muscles are familiarly
known to the physician by inducing a contracted and im¬
movable condition of the articulations influenced by those

CLASSIFICATION OF DEFORMITIES.

muscles ; or paralysis of certain muscles will disturb the
antagonising powers in a limb, inducing deformity. In
these cases, the muscles being primarily affected, the articu¬
lations become secondarily involved. Cicatrices from loss
of substance, as from gangrene, ulceration, burns, &c.,
excite deformity in a similar manner.

The second subdivision of non-congenital deformities
consists, then, of those which arise from causes indirectly
affecting the articulations; and in order to distinguish a
case of this nature from ankylosis, I name it contracture.

A third subdivision of acquired deformities is to be found
in the distortions arising from causes that simultaneously
affect both the muscles and the joints [the active and
passive organs of movement]; such are rachitic deformities,
which you know to be deformities from debility [imperfect
nutrition or assimilation].

Congenital deformities are divisible into two classes.
I shall hereafter describe several distortions, of variable
severity, induced, in my opinion [for the most part], by
derangements of the nervous and muscular systems of the
foetus, independently of any absence or deficiency of parts,
characterised, also, by their capability of restoration to a
surprising degree of perfection. These I shall include
under the head of congenital distortions. In the last cate¬
gory I shall consider those in which, whatever may have
been the primary interruption of normal development in
the foetal parts, a total absence, incompleteness, or mal¬
formation of organs exists. These may be termed con¬
genital malformations.

Every deformity of the human frame with which I am
acquainted is referrible to some one of the above patholo¬
gical heads. Some of my hearers may have observed that
no direct mention has been made of distortions of the
spinal column. But I have already stated my objections
to a classification of deformities founded on regions of the
body. Some distortions of the spine, moreover, are refer¬
rible to tbe first subdivision, namely, ankylosis [causes

10 RELATIVE FREQUENCY OF DIFFERENT DISTORTIONS.

directly affecting the articulations of the spine] ; others
are analogous to contractures [causes indirectly affecting
the articulations of the spine] ; while the greater number
of spinal curvatures belong to the third subdivision of
acquired deformities, namely, rachitic distortions [defor¬
mities from debility].* Here, for the present, I shall close
the subject. In my next lecture I will furnish you with
a diagram, which will serve to shew at one view the classi¬
fication of deformities, and the plan of the course.

• At the establishment of the Orthopaedic Institution (Bloomsbury Square),
I introduced a system of registration of every case of deformity presenting at
that charity. This has been continued since my retirement from the medical
direction. The relative frequency of some distortions is shewn in a valuable
publication of the medical statistics of the charity, by Mr. Lonsdale, in the
Medical Gazette, June 1849, from which it appears, that of 7533 patients,

there were affected with :

Curvature of bones of lower extremity (outwards) .... 1604

Genu valgum, or inward inclination of knee.1843

■ outwards, 635 -i
forwards, 203 >
. inwards, 45 J
„ introrsum et extrorsum, one knee turned in, the other

turned out.

Talipes varus, affecting one or both feet.

,, equinus.

,, valgus, or flat foot.

,, calcaneus.

,, equino varus.

,, ,, valgus.

Compound varieties, such as Calcaneo-valgus, Talipes varus,

and T. valgus of opposite feet, &c.

Contractedjoints from inflammation or accident, wry-neck, &c.
Nervous affections of one or both sides, spasm, paralysis, or

general weakness.

Injuries of bones and joints from fractures, diseases of ditto,

contractions from burns, &c.

Lateral curvature of spine.401 -i

Posterior ,, „ .121 l

Lateral and posterior „ ...33 J

Angular curvature „ .

Malformations of toes, fingers, &c.

combined with curvature

-1

883

109

583

226

151

112

634

138

555

444

7533

LECTURE II.

General pathological phenomena witnessed in deformities—Meaning of
contraction, morbid, transient, and permanent—Influence of repose
of a part in producing contraction—Structural shortening, hyper¬
trophy, atrophy, and adipose degeneration of muscles-^Pathological
changes in the bones and ligaments—Influence of deformity on the
sound parts, on the physical and mental condition of the individual —
Therapeutic means employed in orthopcedy—Deformities from causes
that operate directly on the articulations, namely, injury and disease
—Deformity with complete and partial ankylosis—The mode in which
contraction of parts in traumatic, phlegmonous, scrofulous, and rheu¬
matic ankylosis is produced.

The following diagram will clearly shew the classification
of deformities explained in my first lecture, and the plan
of the course that I then proposed to follow :

Arising from causes directly [imme-
diately] affecting the articulations.

Arising from causes indirectly [me¬
diately] affecting the articulations.

| Arising from causes directly and indi-
h rectly affecting the articulations..

'Complete and Incomplete
Ankylosis [from Ac¬
cidents, Inflammation,
Erysipelas, Rheumat¬
ism, or Scrofula].
'Contractures from Spasm,
Paralysis, Burns [dis-
i eased palmar, plantar,

‘ and cervical faseia, ha¬

bitual retention in one
_ position], &c.
f Rachitic Deformities, De-
■4 fortuities from Debility
l [mal-assimilation].

f Club-foot, Club-hand, Ri-

Congenital distortions.gidity of Limbs of new-

|_ bom Infants, &c.

f Fusion or Absence ofBones
1 of the Extremities, Su-
■{ Congenital malformations.<J pernumerary Parts, Ab¬

normal Fissures, Mon-

L t strosities, &c.

* The above classification was not originally put forth as a perfect means
of arrangement of all known distortions and deformities. Probably no greater

TRANSIENT CONTRACTION.

Before proceeding to consider either of these subdi¬
visions, I shall treat of some of the general pathological
phenomena that may be witnessed in deformities. I shall
continually have occasion to speak of contraction, because
in every deformity certain parts are found either shortened
and contracted, or elongated. The morbid contraction to
which I here refer is sometimes a cause, at other times a
consequence of deformity, and is not uniform in its nature.
Thus, a transient spasmodic contraction of one or more
muscles may produce a transient distortion, as in the face,
an involuntary twitching of the levator labise super, alaeque
nasi, or of the levator anguli oris, and zygomatici, a dis¬
tortion which ceases on the subsidence of the cause which
excited the muscular contraction. Another example of
temporary morbid contraction is sometimes afforded by the
gastrocnemii producing an intermitting form of talipes,
or club-foot. The limb, when examined during a state of
rest, presents nothing abnormal; the individual can volun¬
tarily flex and extend the ankle, but on attempting to
walk, the heel cannot he properly applied to the ground,
an involuntary transient spastic contraction of the muscles
of the calf having produced distortion and lameness. I
shall not at present detain you by explaining this inter¬
esting form of contraction, but shall proceed to speak of
permanent muscular contraction.*

permanent success will attend a classification of deformities than any other
part of the nosological system. The object contemplated was the diffusion
of some light upon the large variety of distortions about that period suddenly
brought into the domain of medical teaching, and the facilitating the compre¬
hension of the pathology of the subject. The lapse of ten years has not shewn
the above arrangement to be substantially incorrect.

* I have witnessed few well-marked instances of well-developed inter¬
mitting contraction of this kind. It frequently exists to a smaller extent in
ordinary cases of spasmodic deformities, as, for example, in certain cases of
talipes. The same phenomenon exists in certain general contractures of young
children,—those produced, as it is probable, at the moment of birth, or during
the earliest days of infantile existence. See Contractures.

CONSTANT CONTRACTION-STRUCTURAL SHORTENING. 13

Permanent muscular contraction may be induced in
various ways. Long-continued repose of a limb in tbe
flexed position has a tendency to produce a gradual short¬
ening of the muscles on the flexed side of the articu¬
lations, so that on the attempt to resume the use of the
member, a contraction of certain muscles is observed to
exist, impeding the movement of the articulations. Or a
spastic action of certain muscles of an articulation may
arise from disorder of the nervous system, producing con¬
stant contraction of the muscles and constant distortion.
Numerous other causes of this condition of muscles exist.
An increase of bulk is an occasional accompaniment of
the state of tonic contraction. The involuntary incessant
spastic action of the muscle tends to an increased deve¬
lopment of the fihrillse and aggregate mass of the muscle
in a manner similar to the effect of voluntary activity
of muscle. This augmented bulk should not be con¬
founded with the apparent increase of bulk produced by
simple contraction of the belly of the muscle, consequent
on approximation of its origin and insertiofi. After a
certain duration of contraction, from whatever cause,
the muscular fibres undergo certain changes in their
intimate texture, which render them incapable of volun¬
tary elongation whenever the cause of the contraction may
be removed.

To this condition of contracted muscles I apply the
term structural shortening. It would appear that under the
influence of repose, the origin and insertion of the muscles
being approximated, the muscular fibres become adapted
in their length to the altered [topographical] relation of
the parts of the member, and loss of elasticity, or of the
extensibility of the muscular fibrillm ensues. Structural
shortening is succeeded by other changes, of which the
most frequent is a diminution of bulk or wasting, to which
the term atrophy is applied ; and some pathologists are of
opinion that atrophy of long continuance has a tendency

HYPERTROPHY AND ATROPHY OF MUSCLES.

to induce a transformation of the muscular fibres, known
as adipose degeneration.*

* I append two of the most remarkable cases of abnormal increase of bulk
of muscle, combined with contraction and adipose degeneration, with which I
have been favoured. These were presented to me in consultation with Mr.
Farish, of Lancaster Place, September 1847. The cases were those of two
brothers affected with very general paralysis,—of the neck, trunk, the upper
and lower extremities. The brothers were similarly affected in every respect;
their disability differed in degree only, having been, on the whole, the most
advanced in the elder.

For convenience of comparison, the particulars of both cases—the one
a boy aged fourteen, the other aged twelve—are placed partly together and
partly in parallel columns.

A. oitat. fourteen. B. atat. twelve.

Both apparently horn without paralysis or deformity; neither had fits.

A. was noticed by the nurse to present
unusually large development of inferior
half of the body, with large head.

“ Just walked alone weakly from table
to chair at age of nineteen monthshad
previously “ never crawled.” Had been ob¬
served to he “ lax;” unwilling to take ex¬
ercise ; had more difficulty in rising from
the ground than his brother; was sluggish
in physical and moral temperament.

With exception of whooping-cough,
which occurred at age of six, enjoyed un¬
interrupted good health. Previously to
whooping-cough, he had gradually acquired
strength, and was able to walk three or
four miles on a level surface, and even up¬
stairs. The gait, however, was peculiar,
his head and body having been inclined
backwards, and “when sitting he was bent
double forwards.” He began gradually to
decline after whooping-cough, was “for a
time almost completely taken off his feet
by it;” from the age of nine to eleven he
declined even more rapidly, and altoge¬
ther ceased to be able to stand. Until
nine years of age the symmetry of the
lower part of the body was very good;
he still possessed power of locomotion,
which was effected “ on the toes,” espe¬
cially on the right toe (talipes equinus),
the left foot at the same time “ beginning
to roll” (talipes equino-varus). At the age
of eleven and a half the muscles of the calf
were as large as those of a well-grown man ,
whilst the ankles were as small as those of a
healthy hoy of his own age. The lower
extremities have usually been cold, espe¬
cially the left foot; has complained of sen-

B. did not walk alone until the age of two
years and a half; “ previously he shuffled
along the floor.” He had previously had
measles, varicella, and symptoms of mesen¬
teric disease; he also cut teeth with diffi¬
culty. He had been so weak, that his
parents had despaired of his recovery.

From the age of five to eight he gained
strength, at nine rode on pony; and al¬
though the general health was so indiffer¬
ent that he seldom for three weeks in suc¬
cession was free from “ a cold” or “ a bilious
attack,” has been stronger in his limbs than
his brother, and did not altogether cease
walking until six months before the pre¬
sent time. Was observed to be stronger
during winter than during summer.

ADIPOSE DEGENERATION.

The effects of structural shortening are more striking
in children than in adults. In both, wasting results from

sation of “pins and needlesat one period
tlie feet and legs could be pinched without
his being aware of it. Sensation is now-
perfect. Contraction “behind the heels”
appeared to commence at age of six, and
has gradually increased to the present pe¬
riod. The shoulders appeared loose, and
upper arm very small, “ so that a stranger
would fear to grasp him J)y the arms.”

Both of these children lie supine the greater part of the day, occasionally sitting in an

16 ALTERATION OF TEMPERATURE, SYMMETRY.

want of exercise, but in children additional impairment of
the muscle takes place from the interruption offered to the
normal development. The study of these pathological
changes, namely, transient contraction, constant contrac¬
tion, hypertrophy, structural shortening, atrophy, and adi¬
pose transformation, often occurring in the above order
of succession in the same distortion, is of importance in
the diagnosis, prognosis, and treatment of deformities in
general.

Structural shortening and diminished growth of one or
more of the principal muscles of a limb, by affecting the
activity of the member, impairs its vegetative functions;
hence a more or less considerable diminution of tempera¬
ture is observed in all extensive deformities. The sym¬
metry of the frame is destroyed, particularly in those dis¬
tortions resulting from disorder of the nervous system, in

sunk rapidly under the attack of an acute internal disorder. At the autopsy the
gastrocnemiiand solei were found to be uncommonly large, colour whitish yel¬
low; traces only of muscular tissue ; the mass being composed of adipose mat¬
ter, apparently occupying, for the most part, the areolar tissue; the posterior
tibial, flex. long. poll, and flex, comm., presenting a slightly pink colour, were
less degenerated than gastrocnemii and solei. The deltoids and sterno-mastoids
as much changed as surales. Tendons unaffected. Spinal muscles small, but
unchanged in structure. Interior of brain and medulla spinalis apparently
healthy. Sheath of cord contained from four to five drachms of serous fluid.
Beneath squamous plate of right temporal bone and adjacent portion of parietal
bone, a plate of bone, concave internally, convex externally, resembling squa¬
mous portion of a temporal bone, but thinner, was found. This abnormal
plate was externally invested by layers of dura mater, to which it had re¬
mained attached on removal of calvarium ; internally it was lined with arach¬
noid. Convolutions flattened and depressed, corresponding to the plate.
Visceral arachnoid thickened, in many places opaque, with distinctly-or¬
ganised deposit, as if from chronic inflammation. Numerous “ glandulse
pacchioni.” The degenerated muscles exhibited abundance of fat cells,
with few traces of muscular fibre; in some fibrillae the transverse markings
were scarcely distinguishable, in others they were quite distinct. Dr. Parker,
who kindly submitted these structures to a minuter examination, detected
“ granular” evidences of inflammation in the matter scraped from arach¬
noid. The abnormal plate presented lacunae of the form of those of foetal
bone.

CHANGES IN BONES, LIGAMENTS, ETC.

which one side of the body has at some period participated.
The muscles on the uncontracted side of the member suffer
not only by remaining inactive through the want of anta¬
gonists, but are further weakened by the mechanical elon¬
gation to which they are subjected.

I have thus far described the anatomical changes occur¬
ring in muscles from deformities in general; the influence
of deformities on the bones should also be considered. Ob¬
servation shews that these structures suffer in their long
and transverse measurements in proportion to the degree of
inactivity to which the member has been subjected. The
textures composing the articulations undergo numerous al¬
terations, both primary and secondary. These will be more
fully described in the subsequent lectures; but to complete
the outline of the pathology of deformities, the shortening
of some ligaments and the extensive elongation of others,
even to the extent of permitting a partial luxation of the
articular surfaces, the abrasion of cartilage and bone, the
formation of “ new joints” should be enumerated.* The
effects of pressure and friction in producing callosities on
parts that are not naturally adapted for such usage, and
the contrary effects of disease on parts that are intended by
nature for pressure, may for a moment occupy your atten¬
tion. The plantar surface of the adult labouring under the
highest grade of club-foot remains as delicate as the palm
of the fairest of the sex, whereas on the restoration of the
member the cuticle and cutis of the sole undergo the changes
necessary to fit the part for treading and locomotion.

The influence of deformity of one member on the op¬
posite sound part is not void of interest; thus for a time an
unusual healthy development takes place, sometimes suc¬
ceeded by a deformity different from that of the part first
affected. The deficiency arising from congenital deformity
of one hand or foot is in some degree compensated for by
the perfection attained by the unaffected organs; but in
* See Plate I. at end of volume.

SECONDARY EVILS OF DISTORTION.

single club-foot, for example, it often happens that the
disproportioned amount of weight borne on the sound foot
produces ultimately that change in its tarsal arch which
constitutes flat-foot.

The effects of distortion on the physical and moral con¬
dition of the individual is one of deep interest. It is un¬
deniable that the consciousness' of an infirmity of this nature
has displayed itself in a most marked manner in many
individuals who have been thus affected. Historians have
described the influence of deformity in alternately stimu¬
lating the cultivation of the worst and of the best passions
and instincts. The impeded development of the trunk from
extensive deformity, or wasting of a member during tbe
growing period of life, often appears to occasion in the
system a reserve-fund of nervous and nutrient energy, which
may be devoted to the elaboration of those parts the de¬
velopment of which is not impeded. Hence the mental
vigour and surprising activity of the unaffected organs.
Deformity of a part of the body may produce effects on
the mind in a manner similar to those of a moderately
sedentary mode of existence, the nervous and nutritive
energies, unexpended in the muscular system, being em¬
ployed to develope and sustain the mental faculties.

[The phenomenon of which the explanation is here at¬
tempted may probably arise from a circumstance of more
general application — the anatomico-physiological state of
the nervous system. It cannot be doubted that mental
activity, in whatever direction it be exercised, is, as well as
corporeal activity, influenced by the more or less extensive
development of portions of the nervous system; and the
study of pathogeny shews that the liability of an organ to
disease increases with its physiological development. This
view should, however, be qualified by the consideration,
that to a certain point development and functional activity
produce only the highest degree of healthy action; but
when excited beyond this physiological degree the action
becomes morbid. Many distortions originate from mala-

INFLUENCE OF DISTORTION UPON CHARACTER. 19

dies of brain and spinal cord; others appear at least to
have been remotely influenced by tbe nervous system of
tbe parent, or of tbe affected individual.

From these considerations the influence of certain de¬
formities upon character may be regarded as an incorrect
expression of a presumed fact. It should rather be stated,
that the character of the individual and the deformity, in¬
stead of standing in the relation of cause and effect, result
both of them from a peculiar condition of the system of
the individual, and in particular of the nervous system.
It is also possible that statistics would shew that the con¬
nexion between deformity and character is only accidental;
marked character, when coinciding with external physical
infirmity, having prominently attracted observation.]

Derangement of health, consequent on the various in¬
jurious influences that I have considered, frequently aug¬
mented by compulsory sedentary habits, is of frequent
occurrence. The protean disorder dyspepsia , and its com¬
panions hypochondriacism and melancholy, frequently re¬
quire special applications of the resources of medicine.

[Hysteria is often superadded to spinal deformity; and
perhaps hysteria is never more puzzling to the practitioner
than when thus associated. It assumes the form of in¬
capacity to bodily exertion, intense neuralgia, paralytic
loss of power, extreme sensibility to cold, and in short
aggravations of all the ordinary symptoms which may ac¬
company the distortion.]

Before detailing the nature and treatment of the first
subdivision of our subject, the deformities arising from in¬
juries and diseases of the joints—ankylosis — I shall offer
some remarks on [the objects and] the therapeutic means
that are employed in orthopaedy.

[Orthopaedy ( opOov ttuBlov*) ; orthopedie, Fr.; ortho-

* Andry, Dean of the Medical Faculty of Paris about 1744, who first used
the term “ orthopsedy,” states that he constructed it from the Greek words
above given. Kraus, in his Lexicon, puts forth ircuSos (genitive of ircus), in¬
stead of tr adiov.

NATURE OF ORTHOPAEDY.

padie, Germ.; ortopedia, It .,—the art of removing defor¬
mities in young children, extended in the present day to
the treatment of deformities in persons of all ages; a branch
of the healing art employed by the Egyptians, the Greeks,
especially by Hippocrates (p. 3); unnaturally raised, how¬
ever, to a speciality in modern times through the neglect of
it by leading men in different countries. This neglect was
probably due to the difficulty encountered in accomplishing
the curative objects of the art at a period when the anatomy
and pathology of deformities were not understood. Ortho¬
paedy, by its employment of gymnastics, touches, on the
one hand, the art of hygeia, and on the other, by the use
of tenotomy, reaches to operative medicine or surgery in
general, whilst by the continued attention to the condition
of the frame required for the cure of many rachitic and
paralytic deformities, it follows the path of practical medi¬
cine.* The great impulse given to the study and treatment
of deformities by the discovery of subcutaneous division of
tendons and muscles by Stromeyer in 1830, has secured
in the service of orthopaedy the labours and researches of
numerous able men, and a consequent extension of the
means of relieving deformities, and promises to lead to dis¬
coveries by which some distortions yet incurable may ulti¬
mately be removed from the list of opprobria of our art.

Orthopaedy has reacted beneficially upon general sur¬
gery, by shewing that many operations de convenance, e.g.
amputations of fingers or entire limbs for removal of defor¬
mities of these parts, formerly orthodox, are in the present
day unjustifiable, and by demonstrating the greatness of
the results obtainable by well-conducted graduated appli¬
cation of force or pressure to articulations in preventing
deformity during diseases of articulations. Moreover, as
the majority of such deformities of extremities are, where
incurable, at least partially remediable, an important ele-

* Whilst discouraging the view of orthopaedy as a speciality, it cannot be
denied that advantage may result from delegating certain functions to the
rubber and instrument maker.

OBJECTS OF ORTHOPAEDY.

ment in deciding on the propriety of amputation of a dis¬
eased joint—namely, the circumstance so often formerly
advanced, that if recovery ensue from the disease of joint,
the limb will remain deformed and useless—is now removed,
and many diseased joints formerly condemned are thus, by
the greater skill and perseverance of the surgeon, saved.

Orthopaedy embraces a large field of practice,—the
removal of congenital deformities, those acquired from dis¬
ease or injury, through weakness of bones, ligaments, and
muscles, spasmodic and paralytic affections. The relief of
certain convulsive affections, such as stammering, certain
chorea-like affections of the hand and other parts, find
their way to, and often their removal at, the hands of the
orthopaedic practitioner.

Until a recent period—the last sixteen years (1852)—
the treatment of many of these affections, when attempted
by otherwise able practitioners, was commonly conducted
in as empirical a manner as by the commonest charlatan.
Without any clear ideas of the pathological phenomena
requiring to be modified or removed, the surgeon, if not
deterred from interference with a deformity through the
fear of encountering hopeless malformation or ankylosis,
regarded the case as simply a mechanical change of form,
and treated it solely upon mechanical principles. At pre¬
sent the objects proposed by orthopaedy consist in facili¬
tating the absorption of plastic matters which impede the
movements of parts, in altering the length and direction
of cicatrices, ligaments, fasciae, tendons, muscles, &c., the
form of bones, the development or re-excitation of weak
muscles, or the restoration of the equilibrium between
associated or antagonist muscles.

We will briefly survey each of these proposed objects.

One of the commonest impediments to the restoration
of form, mobility, and usefulness of a member, after inflam¬
mation, consists in the effusion of plastic matters in and
around articulations, by which the natural movements are

RESTORATION OF LIGAMENTS, MUSCLES,

obstructed, the plastic material becoming more or less
indurated according to the nature of the inflammation and
the time that may have elapsed since the mischief occurred.
This effusion, when simply located among the ligaments,
tendons, &c., occupying the interspaces afforded by the
areolar tissue, is very commonly re-absorbed soon after sub¬
sidence of the inflammation, or it may leave those parts
unnaturally agglutinated by its becoming organised, form¬
ing a new tissue, or so-called adhesions. It is also proba¬
ble that, as one of the effects of inflammation, the usually
flexible ligaments and the elastic muscular tissues undergo
some molecular change, by which these properties of flexi¬
bility (ligaments) and susceptibility of ready elongation
(muscles) are temporarily sacrificed.

The relative length of the various ligaments, fasciae, and
muscles in the vicinity of the joint is usually much affected
in the progress of inflammation of a joint, and the restora¬
tion of the normal proportions between these parts is con¬
sequently one of the objects of orthopaedy. So large an
amount of deformity being commonly witnessed, and so
great resistance to alteration of the position of the limb
being manifested during the inflammation, many writers
on diseased articulations have supposed that a peculiar
spasmodic irritation of the flexor muscles of a joint existed,
by which they have accounted for the shortening of parts,
the deformity and even the sub-luxations so frequent in
inflamed joints.

The mode in which the relative length of parts is dis¬
turbed is intelligible without the supposition of any spas¬
modic irritation of muscles. It is simply necessary to
remember, that so long as the ligaments of an articulation
retain their normal structure and action, the muscles pos¬
sess no power of changing the position of the articular
surfaces and of the limb beyond the movements natural to
the part. When an articulation is inflamed, the effusion
into its interior distends the synovial sac, necessarily sepa-

OF THE ARTICULAR SURFACES-

rates the articular surfaces, elongates the ligaments, (pro¬
bably already involved in the inflammatory process, and
themselves altered in their cohesion, and therefore disposed
to yield,) deprives the muscles of the basis of their actions,
—viz. a suitable degree of fixity in the joint; abnormal
movement of the parts is now practicable, illustrated by
the sufferings experienced on accidental motion of the
limb; the patient probably strives to give that security to
thejoint .no longer afforded by the articular tissues, and by
instinctively acting upon those muscles which are either
normally the stronger set of muscles, or which the con¬
figuration of the parts favours, obtains a comparatively
easy position. In addition to the share which the will of
the patient may have in altering the form of the part, it is
probable that when the will is inactive, the involuntary
power of the muscles is exercised to bring the origin and
insertion-point of these organs into closer contiguity. In
some articulations nearly all the muscles contribute to
contraction and deformity. Thus, in the hip-joint, after
adequate destruction of articular structures has taken place,
the majority of the muscles which connect the femur and
the tibia with the trunk tend to shorten the member.
Sometimes we can study in the deformity itself the share
which a particular muscle has exercised in its production.
Thus in ankylosis of the knee we often recognise the
greater influence exercised by the biceps femoris from the
peculiar outward rotation of the leg produced by that
muscle. The peculiar attachment of the crucial ligaments
has probably also some share in determining the abnormal
position of a knee thus affected. See Knee Contracture. .

The restoration of the direction of articular surfaces is
a frequent object of orthopaedy, and often one which is
effected with comparative facility.

Thus, when in children, from imperfect nutrition or as¬
similation, the muscular and ligamentous tissues are weak,
and particularly if this weakness of ligament and muscle

RESTORATION OF FORM OF BONES.

24 -

be associated with stoutness, the articulations of the lower
extremities especially become deformed, producing the af¬
fections known by the names genu valgum (in-knee) and
talipes valgus spurius (flat foot), which an appropriate
treatment promptly relieves. The separate articulating
surfaces of the ankle and tarsal articulations, in club-foot,
for example, are often much changed in direction, consti¬
tuting a circumstance requiring the utmost attention during
treatment.

In other instances, in which the direction of articular
surfaces is altered, as in severe or complicated curvatures
of the spine, restoration is a matter of extreme difficulty,
and is often impossible.

The restoration of the form of bones is a less frequent
necessity in orthopaedy than was formerly believed. It is
now known from the dissections of Blumenbach, Palletta,
Colies, Scarpa, and of myself, that even in the worst forms
of club-foot the form of the principal bones is little changed,
compared with the deformity of the member. Morbid ana¬
tomy and experience in the cure of ankylosis have demon¬
strated that, even in deformities after disease and injury of
joints, the soft parts are usually more implicated than the
bony structures.

Rickets, is the principal contributor to the necessity of
altering the form of osseous textures; from this disease
extreme deformity often results, and whenever situated
in shafts of long bones is directly amenable to treatment,
provided eburnation has not taken place. Long-standing
extreme spinal deformities oftener present insuperable
obstacles to restoration, owing to alteration of bones.

In the greater number of deformities, especially in the
various forms of spasm: and paralysis, in which the head and
extremities in particular are so frequently involved, ortho¬
paedy is furnished with the opportunity of endeavouring to
effect the remaining objects enumerated—that of the re¬
excitation and development of weak muscles, or the pro-

MEANS USED IN ORTHOPiEDY.

duction of equilibrium between sets of antagonist and as¬
sociated muscles.

Although a matter of minor importance, the artificial
restoration of the length of shortened limbs should be here
mentioned.

Of the means resorted to in the treatment of deformities.

In the infancy of orthopaedy the measures employed
for the relief of deformities were comparatively few. The
gymnastic medicine of the Greeks was doubtless not sim¬
ply employed as a branch of hygiene to prevent disease and
deformity,—as a part of therapeutics in the relief of chronic
disorders and debility,*—but as a means of rectifying phy¬
sical alterations of the frame. Hippocrates, whether or no
he attempted division of tendons in the cure of club-foot, j-
has left upon record in his treatise^ on Articulations an
excellent description of the process of bandaging to which
he resorted, and with which, doubtless aided by manipula¬
tions of the part, he frequently effected a cure. From the

* In the present day we have specialists who devote themselves to the pro¬
fessed cure of internal disorders by gymnastic exercises. If we cannot tolerate
the empirical nse of gymnastics and its claim to be considered the philoso¬
pher’s stone of practical medicine, we can recognise the too common neglect
of corporeal exercise in urban, and even in rural society, and admit the value
of a course of moderate and appropriate gymnastics to those who cannot with¬
out the stimulus of novelty be induced to make bodily exertion. In this mat¬
ter, as in the analogous so-called systems of Mesmer, Hahnemann, Preisnitz,
in the Molken-Cur, &c. &c., the rational or eclectic physician, whilst utterly
repudiating the claims of these systems, may be reminded that the particles
of truth which these empirics have each selected from the accumulated stock
of knowledge of the fathers of medicine, have often been neglected by in¬
dividual regular practitioners. It would be wonderful were it otherwise ; for
so numerous are therapeutic agents, that the practitioner learns to confide
most in those he has most frequently employed, and neglects those to which
he is unaccustomed.

f Symbols ad Talipedibus cognos. W. J. L., Berolini, 1837.

J Vide Sydenham Soc. translation of the Works of Hippocrates, by
F. Adams, LL.D., Surgeon: voL ii. on Articulations.

VALUE OF MANIPULATIONS.

period of Hippocrates until recent times little appears to
have been effected for the improvement of the art; during
the last century several original minds (Venel, Bruckner,
Wan tzel, for example,) devoted themselves to the manu¬
facture of improved apparatus for correcting deviations, or,
as the result shewed in the majority of cases, for simply
supporting deformed members, and enabling their owners
to effect locomotion, and otherwise mix in society with
greater facility.

In the present day the proper available resources of
orthopaedy consist of manipulations, baths, inunctions, gym¬
nastics, mechanical instruments, forcible extension with
aid of anaesthetics, division with the knife of resisting struc¬
tures, electricity or galvanism, and retaining apparatus.

On Manipulations.

Mellet,* one of the most practical writers on this sub¬
ject, says, “ les manipulations sont fame, la partie essen-
tielle de l’orthopedie; et sans elles, il est bien peu de
difformites qui guerissent par l’emploi seul des appareils
mecaniques.” This assertion is equally true, even with the
advantages afforded by the discovery of other means than
mechanical apparatus. Manipulation may be regarded as
the natural remedial agent for a deformity, that which in
the rudest state of society is instinctively employed. Being
simple, apparently easy of application, free from obscurity,
manipulations have not in the present day received the
attention they deserve; they alone suffice for the rectifica¬
tion of slight genu valgum or knock-knee, and recent cur¬
vatures of the shafts of bones: combined with bandaging,
they cure slight congenital deformities of the limbs, or
with bandaging and mechanical apparatus, severer cases of
deformity of numerous articulations. In deformities re¬
quiring operation, or long-continued use of mechanical
* Manuel Pratique d’Orthopedie, 1836.

SHAMPOOING-BATHS.

apparatus, they are indispensable for the obtainment of the
full benefit of the surgical operation or of the apparatus em¬
ployed. They are for the most part grateful to the feelings
of the patient, enable him to bear the continued restraint
of instruments, relax or set free the structures of the limbs,
which are more or less benumbed or painful through inces¬
sant pressure of instruments, facilitate the circulation in
the blood-vessels and lymphatics, procure suppleness to
the articulations, and assist in giving them a favourable
direction, and the habit of normal movement, such as they
will have ultimately to maintain without assistance. In
order to be successful with manipulations, the “rubber”
must proceed with study and gentleness; he should practise
regular movements only, have recourse to them daily, or in
some cases several times daily. Without the use of mani¬
pulations the practitioner has often been mortified with
the discovery, that although he has obtained a straight
member, it has been rigid, as if ankylosed, extremely pain¬
ful when passive movements have been attempted, and but
slowly restored to mobility. A member left too long neg¬
lected in mechanical apparatus without manipulations, may
remain ever afterwards deprived of that extent of motion
in the joints which is necessary for the recovery of full
muscular development, and consequent strength and use¬
fulness.

Each deformity requires a particular form of manipula¬
tions, which will suggest itself to every medical practitioner.

Shampooing is related to manipulations, to which it
mainly owes its efficacy; for in proportion to the extent to
which the shampooer adds flexion and extension movements
to those of kneading the muscles, will he succeed in his
object.

Baths.

As deformities for the most part have contracted phy¬
sical alterations during their progress, it would be unrea-

THE COLD DOUCHE.

sonable to attribute to tbe local or general application of
warmtb and moisture any considerable beneficial influence
in tbe cure of deformities. From all times, however, these
means have been largely resorted to with approbation.
We may trace the custom, still prevalent in remote parts
even of this country, of thrusting tbe paralysed and dis¬
torted limb into the paunch of a recently slayed animal to
the Egyptians. Possibly the popular idea of the value of
this means is not limited to considerations of warmth and
moisture, but may attribute to it some mysterious trans¬
lation of the ebbing vital properties from the body of the
animal to the almost lifeless paralytic limb. We may
admit the aid afforded by warmth to tbe languid circula¬
tion and nutrition of the impaired part, the stimulus im¬
parted to blood-vessels and absorbents by warmth and
moisture, by which the removal of effused and useless
materials is in some deformities hastened, the possibly
soothing influence in functional disturbance of the muscles
themselves, the ruder manipulation which the patient will
tolerate in the bath; but after all, it must be admitted that
baths, local and general, are but auxiliaries upon which
too great reliance, to the neglect of more effective means,
should not be placed.* The cold douche has been largely
employed; the primitive mode of employment having con¬
sisted in bringing the maimed part beneath a natural falling
stream, or beneath a common pump, until the sufferer, if

* The author is unable to speak favourably of much warm bathing of
members whilst undergoing instrumental treatment. He has found that im¬
mersion in warm water of the parts previously compressed by an apparatus
induces tumefaction and increased sensibility, interfering with the proper
replacement of the apparatus. Ablutions are necessary for cleanliness, and
the comfort of the patient demands the occasional sacrifice of some time for
the purpose; but in severe deformities, requiring steady persistence in me¬
chanical treatment, warm bathing should rarely be used. Free washing of
the compressed limb with undiluted spirits of wine answers the purpose of
cleanliness, cools the limb, refreshes the patient, and may be substituted for
every other bath during active instrumental treatment.

INUNCTIONS—GYMNASTICS.

young, often shrieked with agony. The self-distinguished
hydropath has invented numerous mechanical contrivances
to effect a similar purpose. The cold douche of spring or
sea-water judiciously applied, short of acute suffering, if
quickly followed by reaction in the feeble member, may
prove beneficial in restoring tone to it. The contractions
and deformities in which the cold douche is often applied
are commonly of a paralytic or spastic nature. In these
cases it should be remembered that the seat of the diseased
action is usually in the brain or spinal cord, and that conse¬
quently treatment at the periphery is not likely to succeed.
It is right to caution the inexperienced against unguarded
application of cold either to the affected limb or to the
vicinity of the central organ. The remedy is most potent
for evil. The author has witnessed aggravation of disease
of brain and spinal chord clearly traceable to extensive use
of the cold douche to the spine.

Inunctions.

The consideration of inunctions of various substances,
medicated or otherwise, for the relief of deformities, may
be briefly dismissed. They are undoubtedly useful in
promoting absorption of effused materials; they are the
vehicles of counter-irritation in paralytic and spastic con¬
tractures; they combine friction with manipulations, sti¬
mulate the development of caloric in the part, and favour
capillary circulation. The substances most proper for in¬
unction are iodine, camphor, ammonia, lytta, turpentine,
and sometimes mercury.

Gymnastics.

Gymnastics, alternately vaunted and decried, will ever
hold an important place in the estimation of the ortho¬
paedic practitioner.

We may include under gymnastics every species of

MECHANICAL INSTRUMENTS.

voluntary exercise of the muscles which is calculated to
restore power or harmony to the movements of the limbs
and trunk. Gymnastics consist of the patient’s voluntary
active (artistic) use and exercise of the muscles, and are
the complement to manipulations, which consist of passive
movements performed by another person, or, when prac¬
ticable, by the hand of the patient himself.

The occasional depreciation of gymnastics has naturally
resulted from the tendency of the professors (!) of the art
to over-estimate its advantages, and to undertake to effect
impossibilities—the cure of serious deformity by its means
alone. Sometimes also gymnastics have been pushed to
the extent of permanently impairing the vigour of the
frame of the growing youth. It may almost be said of
some of the modern gymnastic teachers that which is re¬
corded of Herodicus by Plato, that he destroyed himself and
many others by undue gymnastic exercises. An occasional
accident during violent gymnastics has also tended to di¬
minish confidence in their employment. The application
of gymnastics to each deformity will be found in its ap¬
propriate place. See Spinal Curvature, Wry Neck, &c.

Mechanical Instruments.

Until recently the employment of mechanical contriv¬
ances constituted the most influential means of rectifying
deformities possessed by the orthopaedic practitioner; and
notwithstanding that subcutaneous tenotomy and myo¬
tomy enable surgeons in the present day to effect more
in one minute towards the cure of many deformities than
was formerly accomplished during months’ and years’ as¬
siduous use of instruments, the complete restoration of a
deformed part is usually only possible when the surgical
operation is succeeded by appropriate mechanical treat¬
ment. In addition to this necessity of mechanical means
as an adjuvant, and as an indispensable means of per-

MODES OF APPLYING MECHANICAL FORCE.

fecting restoration in cases in which an operation has been
performed, the profession is still indebted to the labours
of the instrument maker for the means of curing, without
the necessity of operations, many deformities arising from
contracted muscles and tendons, such as the slighter cases
of club-foot, and numerous deformities of bones and articu¬
lations arising from weakness and rachitis.

The orthopaedists who practised before the discovery of
subcutaneous tenotomy—a discovery which has since re¬
volutionised the treatment of deformities —had to a great
extent perfected the manufacture of instruments. The
important influence in the cure of deformities exercised
by these means renders it desirable to examine the prin¬
ciples upon which they should be constructed.

Great ingenuity has been displayed in their manufac¬
ture, and many complicated contrivances have been em¬
ployed in the application of the mechanical force. Occa¬
sionally considerable demands upon the skill and ingenuity
of the mechanist are required; but, as a general rule,
elaborate instruments should be avoided. They are often
strictly articles of luxury, not obtainable for the treatment
of the majority of cases of deformity that present them¬
selves in private, and especially in public, practice. The
masters of each department of the art of healing have
constantly laboured to simplify the means used. This ex¬
ample should be imitated by the orthopaedic practitioner,
endeavouring, as far as possible, in the exercise of his art,
to be independent of extrinsic aid. The author highly
appreciates mechanical apparatus, but can safely add, that
when nothing can be effected for the cure of a deformity
without a costly instrument, very little can be accomplished
with its assistance. In mechanical instruments different
applications of mechanical forces are employed,—the lever,
the screw, the spring; the last two often resolvable into the
lever, screws and springs being often employed to modify
or facilitate the action of the lever. In the simplest appa-

APPLICATION OF THE LEVER

ratus, such ‘as the wooden splint or iron stem employed
for the straightening of a curved bone, the middle of the
splint is sometimes made to rest upon the prominent point
of the hone, as at a , whilst hy means of suitable straps
applied at b and c, the extremities of the curved
bone are drawn towards the splint, on the same
principle that a bent stick is straightened across
the knee. At other times, as in genu valgum
or knock-knee, and in curvatures of bones, the
ends of the splint or of the iron stem are applied
at parts distant from the deformed part. Thus,
the ends of the splint (fig. 2), d and e, are ap¬
plied, suitably padded, against the trochanter
and malleolus externus, whilst by a bandage at
/, the knee is gradually brought to a proper direction with
the shafts of the bones. The force is similarly applied
to a curved bone (fig. 3).

Again, in the early stage of the mechanical treatment
of talipes varus or club-foot, the same simple process is em¬
ployed, whether a straight tin or wooden splint be used;

Fig. 2. Fig. 3. Fig. 4.

the middle of the splint, as at g, fig. 4, being applied against
the outside of the ankle and tarsus, whilst the upper part
of the tibia, h, and the toes, i, are drawn by straps or
bandages towards the ends of the splint.

IN CLUB-FOOT, SPINAL CURVATURE.

Even in severe club-foot, requiring more complicated
means, and in the advanced stage of the treatment* whilst
other objects are simultaneously pursued, the removal of
the unnatural curve of the foot and ankle is effected by the
steady application of some principle of mechanical power,
as in the author’s modification of Scarpa’s shoe, now com¬
monly used in treatment of varus, and known as “Dr.
Little’s shoe.”

In this apparatus (fig. 5), two springs, b and c, repre¬
sent the splint of fig. 4. These two
springs meet on outside of the ankle,
against which, properly padded, they
are applied; the extremities of the
springs being brought against the upper
part of the leg and the toes, reduce the
curve of the dorsum pedis and the
altered direction of the ankle-joint, in
a manner similar to the action of the splint in fig. 4.

In apparatus for rectification of deformities of the spine
the mechanical power is applied in the same manner. Thus,
in rachitic posterior, and sometimes in angular
curvatures, the metal splint or upright, ap¬
plied longitudinally to the spine, rests against
the projecting part of the column, as at a ,
fig. 6, the extremities of the stem being made
to act as a double lever above by bands around
the shoulders and chest b, and below around
the pelvis c. This contrivance may often be
superseded by a common wood, leather, or
gutta-percha splint, secured by the ordinary
bandage.

In lateral curvature the principle of the
lever comes powerfully into operation when
its action is understood and properly applied. The majority
of apparatus for this deformity are mere supports, being
entirely deficient in the essential matter which should give

34 ,

Tavernier’s lever belt.

to the apparatus the force of the lever. Thus, Tavernier’s
lever belt (fig. 7), one of the most simple
and scientific combinations for relief of la¬
teral curvature, is comparatively inopera¬
tive unless the fulcrum upon which the
lever acts is rendered as immovable as
practicable upon a movable living body
(as at c).

The screw in orthopaedic apparatus is
properly employed as a means of graduat¬
ing the adjustment to the affected parts,
and not as the powerful means its name
indicates, of forcing protruded or bent
Fig.i* parts into a proper position. The living
structures do not with impunity tolerate the brute force of
the screw, or indeed of the lever itself. When the apparatus
is adjusted to the deformity, the tightening of an additional
band, or an additional turn to the screw, brings the ap¬
paratus in close contact with the displaced part.

I may adduce the male and female screw in the common
splint for bent knee as an illustration of the use of the screw
in orthopaedy. See Knee ankylosis. This apparatus consists
of two splints adjusted to the leg and thigh, connected under¬
neath by the screw in question. The screw is not designed
to force the bent knee into a straight position,, but is em¬
ployed for the purpose of varying the angle at which the
leg and knee splints are fixed in relation to each other.
The work of straightening the limb is effected by a series
of straps or bandages by which the limb is secured in the
instrument. The most effective of these straps or bandages
is that which passes over the contracted joint; and it will

* a, metal rod contrived to act as a lever for rectification of lateral curva¬
ture ; b, circular band of covered metal, or of leather, to encircle the hips;
d, an inelastic band attached in front to the hip-band, and behind to the lever,
which, when sufficiently adjusted, tends to replace the lapsed ribs and vertebrae ;
c, a strap passed between the legs, or, still better, beneath the heel, to effect
counter-extension.

VALUE OF METALLIC SPRINGS.

appear strange to mention that in the majority of knee
splints of this description which the author has seen, the
principal strap was absent, either through unnecessary fear
of pressure over the femur and patella, or through ignorance
of the principle on which the apparatus should be applied.
In the ordinary ratchet-wheel mode of applying the screw
the same explanation applies.

It should be thoroughly borne in mind during the em¬
ployment of the screw in orthopaedic apparatus, that it is
available not as a means of forcing the deformed parts
into their natural position, but simply as an adjusting con¬
trivance. In any case in which the force of the screw is
employed, unless for a very brief period, excoriation,
sloughing, intolerable pain* in the parts compressed, will
inevitably result; the lapsed part should be rather solicited
into its place by the more gentle arts of the bandage, than
coerced by the unyielding and unfeeling screw.

The metallic spring constitutes an important mechanical
power frequently applied in orthopaedy. Occasionally its
action resolves itself into that of the lever, but is preferable
in certain cases on account of greater facility of adjustment,
and because its flexibility permits a certain degree of move¬
ment in the apparatus, grateful to the patient’s feelings.
The spring has the further advantage that, wherever appli¬
cable, the bandages or straps employed to connect the
spring with the part are not required to be so tightly
secured as in the application of the inflexible lever. The
spring as employed for these purposes is represented in
fig. 5.

Springs are often useful adjuncts to other apparatus, for
the purpose of neutralising the preponderating action of
some muscles, or for assisting the action of those which are

* In some patient individuals vesication, and even small sloughs, may be
induced on integuments over projecting bones without complaint of pain,—a
powerful reason for anxious examination of a part subjected to pressure.
Large sloughs are more than inexcusable.

36 WORTHLESSNESS OF MANY “ SPINAL SUPPORTS.”

weak or partially paralysed, and in some cases for wholly
supplying the place of a totally paralysed or absent part.

Thus, in partial paralysis of the anterior tibial, the
quadratus tibiae, or of psoae and iliacus muscles, the spring,
applied in many different modes, is often of essential ser¬
vice in raising the toe from the ground, straightening the
knee, or in elevating and projecting forwards the femur
during the act of walking. Springs composed of caoutchouc
or spiral wires are advantageously resorted to to supply
the action of the muscles of the calf in paralysis and atony
of those parts, upon the same principle that Mr. Gray, the
manufacturer of artificial legs, employs them as an inge¬
nious substitute for the same structures.

In this general review of the mechanical means of treat¬
ing deformities, it is unnecessary to give other examples of
the application of the lever, screw, and spring; these will
be found under the head of the several deformities.

Gradual, elongation, of parts, as of the spine, by “ exten¬
sion-beds,” and partial suspension by head and neck, have
frequently been employed. See also Knee-extension.

A large proportion of mechanical contrivances is in¬
cluded under the head of supports; thus, iron stems, jointed
opposite the articulations, are often applied on one or both
sides of the lower limbs, as a mere scaffolding to support
weakened parts; or when the same are firmly secured
around the pelvis, or even higher on the trunk, they are
used for the purpose of diminishing the weight of the
upper part of the frame borne by the legs. This is effected
by the transmission to the ground of a portion of the
weight directly through the apparatus, the body being in
part suspended as it were upon it. Many forms of spinal
apparatus “for the cure of lateral curvature” possess no
curative properties whatever, are framed upon no principle
calculated to counteract the displacing tendency. How¬
ever much they differ in outward form, by the variation of
a screw or two, by the complication arising from the num-

SIMPLICITY DESIRABLE IN ORTHOPAEDIC APPARATUS. 37

ter of pieces of which they are composed; hy the difference
in the contrivance of “ crutches,” by which the removal
of the weight of the shoulders is attempted, the majority,
either through ignorance of the pathological conditions, the
principles of mechanics, or through the difficulty of reduc¬
ing these principles to practice, act but as mere supports,
and possess not the slightest claim to confidence as means
of rectifying the deformity. They differ not from a com¬
mon wooden splint, except in their ingenuity and costli¬
ness, their facility of concealment and application, and in
their property of mystifying the patient or friends. The
principal requisites of every orthopaedic apparatus are sim¬
plicity, facility of application, and the utmost lightness
compatible with the object to be effected. They should
not tightly encircle the whole limb or trunk, especially
where important nerves and blood-vessels are situated, in
order in some instances that the natural movements of the
. part should be impeded as little as possible, and in others
that the circulation of blood and nervous influence be not
interrupted. A little reflection will convince the reader
what will be the condition of muscles, nerves, and blood¬
vessels loaded with heavy instruments and circularly com¬
pressed, either by iron plates or leather straps. If their
use be not discontinued by the patient himself, either
through the pain and inconvenience they occasion, and
often even, as the author has witnessed, through the large
excoriations they have produced, the vessels and nerves
being compressed supply the limb with diminished quan¬
tity of blood, life, and warmth, the muscles previously
weakened by their displacement, or by the forced elonga¬
tion caused by the deformity, instead of acquiring strength,
daily experience a greater loss of tone and bulk.*

An orthopaedic apparatus, to be truly useful, should,
indeed, be as simple as possible, and like the apparatus for

* The writer has perused no author who has given so practical a view of
the objects and effects of mechanical apparatus as Mellet (Manuel Pratique
d’Orthopedie, 1836), or one whose experience so much accords with his own.

RULES FOR APPLYING INSTRUMENTS.

fractured limbs, should compress the limb in its circumfer¬
ence as little as possible, and never tightly encircle it. It
should act gradually, in proportion as the deformity itself
gradually changes its form. It is, moreover, necessary that
all orthopaedic apparatus be frequently removed and reap¬
plied after a few suitable manipulations, that the persons
entrusted with their application continually watch their
efforts, and thoroughly understand the manner in which
they are intended to act. They must be thoroughly pene¬
trated with the maxim which the author has always en¬
deavoured to inculcate in oral and other teaching, that arte
non vi is the only mode in which the cure of deformities
is worth the accomplishment. They must be prepared op¬
portunely to modify the action of the several parts of the
apparatus, and effect by their instrumentality an almost
invariable amount of curative or replacing influence.

At the outset of their application the practitioner should
be content simply to apply the instrument to the deformity,
and not to apply the deformity to the instrument, as is too
often attempted by novices in orthopaedic practice. In this
gentle manner of proceeding, the first difficulty in the treat¬
ment of every case of deformity is overcome,—the patient
suffers nothing from the attempt to straighten the part;
the simple inconvenience of wearing an apparatus, the irk¬
someness attendant upon necessary confinement of the af¬
fected part in an unfamiliar instrument, is his only trouble,
and one which is speedily, in a day or two, overcome.
Having once applied a well-fitting instrument, the screws
or straps by which it is adjusted to the now improving
member require to be advanced or tightened as opportunity
offers. An impatient advance of the pressure will, by
production of pain, and necessity for relaxation of the
instrument, occasion loss of time. The principle of action
in the progress of mechanical treatment should be that of
never advancing too rapidly, so as to risk the necessity of
receding. By gentle means, and uniform steady advance,
the patient’s confidence, so essential to prompt recovery,

VALUE OF GENTLE TREATMENT.

remains undiminished. By subjecting tbe member to no
greater pressure than can be easily borne, no temptation to
loosening tbe apparatus is afforded to tbe timid, and no
risk is incurred of occasioning excoriation or inflammation
in individuals possessing greater endurance, or in infants,
whose cries may be attributed to other causes. In this
manner, in suitable cases tbe opposition afforded to restora¬
tion by fasciae^ tendons, ligaments, and ill direction of ar¬
ticular surface, apparently irresistible, may, with the further
aid of manipulations, be removed.

In the choice of mechanical apparatus, the surgeon
should also be guided by that principle which actuates him
in the selection of therapeutic agents in any internal or
external disease, viz. the use of that means the action of
which he best understands, or in the use of which he has
had most experience. A common splint, properly applied,
will effect more benefit than an instrument of greater pre¬
tension indifferently managed. “ He should never lose
sight of the circumstance, that, however well constructed
and serviceable the apparatus may be, and with whatever
care and solicitude he may apply and re-apply it, the re¬
covery of the patient will not be directly due to the in¬
strument, but to the manner in which it is adjusted, and
to the numerous modifications made in it during the treat¬
ment ; modifications which cannot always be foreseen, which
may consist of trivial matters, but are sufficient to accelerate
the progress of cure. In the cure of a club-foot, for ex¬
ample, however well applied the instrument may have been
on the first day, however great the care bestowed in ban¬
daging and manipulations, the instrument, at the expira¬
tion of two or three days, will cease to effect any good if
continued in the same way; for, if the apparatus has
hitherto effected nothing, there is something wrong either
in its construction or application; some alteration, perhaps
trivial, as of a strap or cushion, is therefore necessary. If,
however, the apparatus has produced effects, then its direc¬
tion and the primitive resistance are changed; the apparatus

40 DEFORMITY FROM BADLY UNITED FRACTURE.

consequently must be readjusted. The same thing will
recur a day or two later, and so on until the end of the
treatment.”*

From all these considerations, it is apparent that much
harm will result, in the great majority of deformities, from
the habit sometimes pursued of keeping a deformed part
many weeks in succession in an apparatus without the re¬
moval so necessary for the purpose of cleanliness, manipu¬
lations, and readjustment. Among the evil consequences
of too long retention of instruments, often combined with
unsuspected excessive pressure, the author has frequently
witnessed excoriations and sloughs, the production of an
opposite kind of deformity, as the conversion of varus into
valgus, and a degree of rigidity of the part, which has re¬
quired weeks of painful manipulations and stretchings be¬
fore the natural movements have been possible,—sometimes
indeed entire mobility of an articulation has been rendered
impossible. In concluding this subject, the author may
add, that in his experience the power and efficacy of
suitably contrived and adjusted mechanical apparatus is
almost unlimited in the removal of abnormal changes of
form, even the more solid parts, as the bones cannot long
resist well and continuously applied pressure. The author,
confiding in the resources of mechanism, several years since,
in consultation with Mr. Allen of Smarden, Kent, advised
the attempted restoration, many months after the accident,
of a fractured femur badly united, at a right angle, in a lad
of good general health, free from fragiUtas or mollities
ossium.j- The femur was completely straightened, and the
limb thoroughly restored. Doubtless a femur fractured
many months previously, reunited with deformity, can be
straightened with greater facility than a sound femur can
be bent: the case in question, notwithstanding, illustrates

* Mellet, opus cit.

f Dupuytren (Sydenham Soc. edit.) thought sixty days the utmost limit
within which it is admissible to attempt cure of deformity in callus ; Jacque-
.min three to four months.

FORCIBLE EXTENSION DURING INSENSIBILITY. 41

how much may be effected in a class of cases usually deemed
irremediable after expiration of so long a period.

Forcible Extension, with the aid of Anaesthetics.

Under the head of manipulations and stretchings, the
value of gentle employment of pressure with the hands has
been shewn, as a means of curing slight deformities, and as
an important auxiliary to other methods of treatment. If
a larger measure of pressure or force he used with the
hands, the treatment becomes that denominated violent
extension. Here, as elsewhere, it is difficult to draw an
arbitrary line, and say where gentle manipulation ends and
violent extension begins. In practice of manipulations the
competent operator may frequently avail himself of the
smaller degree of sensitiveness displayed by some patients,
of the momentary abstraction of the patient’s volition from
the muscles (a circumstance instantly felt by the hand of
the operator), and apply an amount of force which approxi¬
mates to, or may be considered as, violent extension. But
violent extension with the hands is rarely efficacious in the
removal of considerable contraction and deformity, espe¬
cially in full-grown persons, because either the pain pro¬
duced is intolerable, or the voluntary resistance offered by
the muscles of the patient exceeds that at the command of
the operator; a struggle is maintained between the patient’s
muscles and the rubber, in which the suffering member is
commonly victorious.*

Through the inability of one person to effect, with any
effort of his will, an extension forcible enough to overcome
severe contraction, violent sudden extension, by means of
the combined strength of several assistants, or by means of
powerful screws, brought suddenly into action, was pro¬
posed and carried out, with varying success and misfortune,

* A well-known rubber and instrument maker once informed me, in the
most satisfied manner, that be bad “ broken many a tendo acbillis” in children;
but added, that he did not “ like it.”

42 MANIPULATIONS WITH AID OF CHLOROFORM.

by Louvrier, DiefFenbach, and others (p. 61). In the less
severe cases of deformity, those indeed which are curable
by gentler means, without longer duration of treatment,
the parts were suddenly straightened by violent extension,
without ultimately mischievous results, and the expected
benefit was obtained. But in severer cases of deformity of
many years’ existence, in which organic changes of greater
magnitude had taken place, as in severe knee-ankylosis,
from extensive suppuration about the articulation, with
necrosis, violent separation of adhesions, and snapping
asunder of bony deposits in the poplitial space and else¬
where, were accompanied with laceration of blood-vessels
and nerves, fractures of the bones themselves, and conse¬
quent inflammation, suppuration, and even mortification,
of the member. The plan was deservedly denounced, and
fell into disuse. See Deformity from Ankylosis.

The art of surgery has, however, recently received an
invaluable addition to its means of usefulness, by the dis¬
covery of the anaesthetic properties of ether and chloro¬
form ; and orthopaedic practitioners have not been slow in
availing themselves of the assistance these means are cal¬
culated to render in the cure of deformities. Hence the
employment of forcible extension with the aid of chloro¬
form or ether. By chloroformisation, the two great ob¬
stacles to the employment of force adequate to straighten
or bend a contracted limb, namely, pain and voluntary
muscular resistance, are removed. As soon as these impe¬
diments disappear, the hands of the single operator, and
his single mind, applied to the parts, encounter the physical
resistance only of the deformed parts; comparatively gentle
manipulations now acquaint him with the nature and amount
of difficulty; he can feel his way in the application of
greater force; feels and perceives the resistance of parts
successively overcome, in an anatomical order; if greater
rigidity still oppose, a few movements of the joint back¬
wards and forwards prepare the way for a more extensive
yielding; and often the practitioner has the satisfaction of

AMOUNT OF BENEFIT DERIVABLE.

being able to effect every natural movement of tbe joint,
and satisfy himself that a cure is obtainable.

Chloroform! sation, with manipulations, and the use of
a certain degree of force, is often of great service as a means
of diagnosis; by it the practitioner is enabled to ascertain
what proportion of the deformity is due to shortening of
soft parts, and how much mischief the articular surfaces
may have undergone. He may have reason to conclude,
from the amount or nature of the resistance, and the
change of articular surfaces, that restoration of the form
and functions of the part is impracticable, and thus save
much time, which without choroform might have been use¬
lessly expended in an attempt to straighten the part.

After straightening or bending the limb, as the case
may have required, by means of this forcible procedure,
the part should be lightly secured in a retentive instru¬
ment or upon a common splint, adjusted so as to maintain
the position more favourable: than that which obtained
before the operation, though not in the new position, i.e.
the entirely straight or bent position into which the hands
of the surgeon may have brought it. For as soon as the
effect of the chloroform upon the sensorial system disap¬
pears, the patient will arouse to the conviction of the
violence which may have been employed, the part may be
acutely painful, and incapable of sustaining the pressure of
a tight bandage or ligature.

The author has usually contented himself with the
increased knowledge obtained of the nature of the case,
with the satisfaction of knowing that the part could be
improved in form and function, and that as the resisting
parts had once yielded, that they would afterwards oppose'
less resistance to cure; whether the means subsequently
employed should be simple manipulations, the use of
mechanical apparatus, or repeated administrations of chlo¬
roform, and “ forcible extension.” The surgeon who
should attempt the forcible binding down of a long de¬
formed limb immediately after “ forcible extension,” would

EXTENSION WHEN INAPPLICABLE.

betray a lamentable ignorance of the pathological condition
of the living parts in the immediate vicinity and within the
diseased, articulation. Although the muscular structures
may have yielded under chloroform, and indurated fasciae
and old adhesions may have been overcome by tearing, it
will be remembered that much adaptation on the part of
nerves, blood-vessels, and absorbents to the altered position
of structures needs to be accomplished. The author has
found that, by taking moderate means of retaining as
much improvement after the forcible extension as can be
borne by the sufferer, by unsparing use of lotions of spirits
of wine, no inflammation of joints thus straightened has
supervened. He has witnessed no untoward accident; and
by employing the ordinary means of gradual extension,
and repeating once or twice the chloroform, and complete
extension whilst the patient lay under its influence, he
has restored cases, the relief of which would have required
many months of ordinary treatment, or would otherwise
have constituted very mediocre cures.

The cases suited for this proceeding are mainly those
of partial or suspected complete ankylosis, resulting from
former chronic and acute diseases of joints. It is perhaps
not superfluous to remark, that the use of “forcible ex¬
tension” is less defensible in cases of recent disease of
articulations than even other active attempts to restore
the form in such cases. In a diseased joint the practi¬
tioner has to note not only the local disorder, but also
the general condition, of which the local affection is but
one manifestation. "When the surgeon, with ability and
experience, has cured the local disorder, i. e. removed the
inflammation, healed the ulcerated or suppurating parts, or
effected subsidence of pain, heat, and tumefaction, the con¬
sequences of the diseased action, contracture and rigidity
only remaining, he has not necessarily cured, by internal
and general therapeutic measures, the morbid constitutional
state. This often slumbers after subsidence of local dis¬
ease, and he should pause ere he too hastily undertake the

SUBCUTANEOUS DIVISION OF PARTS.

restoration of form and movements by forcible extension
under chloroform or by other active measures, and thus
incautiously evoke renewal of local disorder.

Division with the knife of resisting structures .

This influential adjunct to orthopaedy has in some of
its details been long practised ; as, for example, in division
of cicatrices for relief of deformity occasioned by bums,
the separation of palmar fascia in deformed fingers and
metacarpus from contracture and rigidity of this part, the
division of sterno-mastoideus for relief of wry-neck, and in
some analogous operations, which fall rather under the pro¬
vince of surgery in general than of orthopaedy. More
recently (since 1831, the date of Stromeyer’s discovery of
subcutaneous tenotomy), a gigantic stride in bringing within
the domain of cure deformities previously unapproachable
by the regular practitioner has been effected. Orthopaedy
is in a position to affirm that few deformities of the mem¬
bers exist, not being amenable to the modes of treatment
hitherto detailed, in which partial relief, if not positive
restoration, is not procurable with the additional aid of
subcutaneous tenotomy. So large and almost universally
applicable an addition to the resources of orthopaedy has
tenotomy proved, that it will form the principal subject in
another lecture. The consideration of division of fasciae is
also, for practical convenience, referred to another part.

Electricity.

, Electricity in its different forms, electro-magnetism and
galvanism, has been much vaunted for the cure of irregular
muscular action and the weakness attendant upon many
deformities. It is believed by many, from a supposed simi¬
larity to the nervous fluid, to be capable of supplying the
place of that fluid to the disordered muscles; or it is consi-

ELECTRICITY SELDOM APPLICABLE.

dered to act as a stimulus to the nervous centres and the
muscular fibres, by which the disengagement of nervous
and muscular power becomes excited, and a co-ordination
of movements on the part of the muscular fibres and re¬
newed strength in the limb effected. It is much to be
desired that any agent could be discovered capable of pro¬
ducing these beneficial results; but experience, which in
medicine strips the veil from so many delusions, demon¬
strates that which morbid anatomy equally indicates, that
the more severe and ultimately inveterate cases of paralysis
with deformity depend upon organic alterations, in the re¬
moval or cure of which electricity effects nothing benefi¬
cial ; whilst in the less formidable cases of paralysis and
contracture, depending upon functional or transient struc¬
tural changes, electricity is not required for their relief,
were it even demonstrated that this agent is always opera¬
tive for good and never for evil. The confidence enter¬
tained by its advocates reposes doubtless upon some facts;
no remedy not apparently useful could sustain its reputa¬
tion beyond a very limited time. The laws of distribution
of the electric fluid offer some resemblance to those of the
nervous system; hence a prestige in its favour as a means
of supplying a deficiency of nervous power in the part or
nervous system. Applied to a paralysed part in a certain
mode, it commonly produces (involuntary) movements,
which are gratefully witnessed by the sufferers as the har¬
binger of future recovery of voluntary power. Qui vult de-
cipi decipiatur. The electricity acts probably as a mecha¬
nical stimulus to the muscular fibres, in the same manner
as frictions and manipulations, and consequently may, in
the convalescent case, assist recovery. But the hopes en¬
tertained of its ultimate efficacy are soon dispelled, except
in these more favourable cases.

The majority of cases of paralysis occurring in early
life are independent of organic disease, or result from struc¬
tural changes—serous or lymph effusions—removable in

RETENTIVE APPARATUS.

time under the influence of recovered general health and
suitable hygienic conditions. They do not therefore require
the aid of a means of doubtful value. A great responsibility
is incurred in denouncing any remedial means; the author
considers it his duty to state that he has witnessed several
cases of paralysis in children in which, after the use of
electricity, improvement has been arrested, whilst wasting
has ensued with uncommon rapidity. The action of the
electricity upon the part has been manifested by the in¬
creased heat and trembling or convulsive movements usually
observed in the part during its application. If the agent,
powerful as it undoubtedly is, has not ultimately proved
beneficial, it may have occasioned the aggravation. The
paralysis of childhood, moreover, occurring during a severe
illness, is usually at its maximum at the commencement*
—at the moment of seizure: such cases either remain sta¬
tionary, which is rare, or they gradually recover, partially
or wholly, in the course of weeks, months, or years. If a
case slowly recovering, according to the rule, is suddenly
arrested in its improvement, or retrogrades, electricity being
in use at the time, whilst other causes of deterioration are
apparently absent, it is not unreasonable to apprehend that
the electricity has occasioned the mischief. The least that
can be stated against electricity in paralysis of childhood
is, that it is a potent agent, and one the use of which is
not to be disseminated as innocuous and indiscriminately
applied in every case of paralysis, which, if recovering
slowly, is nevertheless pursuing the normal course of this
serious affection.

Retaining Apparatus.

Numerous instances occur in the treatment of defor¬
mities in which an apparatus to retain weak or recently

* It is the contrary with the deformity, which is usually augmented in
proportion to the duration of the paralysis.

PREVENTIVE, PALLIATIVE, MEANS.

recovered parts is indispensable. These means are most
frequently available in the bead, spine, and lower ex¬
tremities. In cases of recently restored articulations, the
ligaments and muscles in the previously prominent or
lapsed side of the articulations are incapable of supporting
the part in its natural direction. Thus, after the restora¬
tion of knock-knee, the ligaments and muscles situated on
the inner side of the joint having remained for a time
lengthened and relaxed, are unable to support the joint
and prevent relapse; hence a retentive apparatus, similar
in principle to that employed for removal of the deformity,
is required. The same observation applies to the neces¬
sity of retentive apparatus in the majority of cases of club¬
foot after operative and mechanical treatment. In suc¬
cessfully conducted treatment, the use of these retentive
means should not, in the growing person, require to be
prolonged beyond a few months.

It is unnecessary to enter here into details of retentive
apparatus required after different deformities; in principle
they should correspond with those used to effect the cure;
but the principles of lightness, simplicity, and portability
require even greater attention. They may consist of springs,
to supply the place of wholly paralysed, or to assist the
action of partially paralysed muscles; flexible or jointed
stems of iron, wood, whalebone, leather, and gutta-percha
splints, to maintain the straight line of parts; elastic wire,
india-rubber, cotton, and other bandages, to supply the
support afforded in health by the tense or elastic fasciae
and cutaneous envelopes.]

I have already defined orthopaedy to consist of the
art of preventing and correcting deformities, and therefore
the principal indications in the employment of therapeutic
means may be divided into—1, the preventive ; 2 , the pal¬
liative; 3, the curative.

The means which are simply preventive in one case
become palliative in another, and curative in a third. The

PREVENTION OF DEFORMITY.

value of each will be apparent on reference to tbeir em¬
ployment in the different classes of deformities. Thus, in
inflammation of an articulation, or in paralysis of a mem¬
ber, the practitioner, by proper position, by well-timed
manipulations, and by appropriate exercises, endeavours
to prevent contraction and deformity; or, aware of the
tendency to distortion in young persons of delicate organ¬
isation, he employs those medicines that are calculated to
increase the vigour of the constitution, and enjoins those
habits, postures, and exercises calculated to prevent ex-
cassive activity of one part and inactivity of another. In
other cases, as in some contractures from paralysis, the
practitioner, conscious of the improbability of cure, con¬
fines his treatment to palliation of the evil by mechanical
elongation of contracted parts, the adaptation of proper
instrumental support, and attention to the general health
of the individual. In curable cases of each variety, the
palliative means may become curative when combined
with the internal use of medicines calculated to relieve
the state of the internal organs on which the paralysis
may have depended.

In rachitic deformities the various means already enu¬
merated, in conjunction with suitable diet and medicines
for amending the digestive and assimilating powers, and
thereby improving the quality of the circulating fluids, the
tone of the nervous, muscular, and other systems, prove
essentially curative.

On Distortions arising from wounds and diseases of Joints ,
Accidents , Rheumatism, &;c.

I shall now proceed to that first subdivision of our
subject, which consists of a class of deformities that are
produced by causes operating in a direct manner on the
articulations. These causes are injuries and diseases of
the joints, the resulting deformities and impairment of

ORIGIN OF ANKYLOSIS,

function constituting the partial and complete “ankylosis”
of writers. By “ankylosis” is meant stiffness, rigidity,
or adhesion of a joint.* The term includes also the ex¬
istence of distortion, as in the majority of cases the part
is fixed in a position which is different from that which
is assumed in the quiescent state, and is accompanied with
a change of form detracting from the symmetry of the
limb. You are aware that ankylosis is divided into false
and true, or partial and complete. When described as
partial, such a degree of impediment to the motions of
the joint is implied as materially interferes with its func¬
tion, hut without any union, or with merely membranous
adhesion of the articular surfaces. By complete ankylosis,
on the contrary, is understood a perfect ossific union of the
articular surfaces, and consequent incapability of restora¬
tion to function.

I shall for a short time occupy you with the manner
in which a joint becomes ankylosed or deformed (for the
terms may he almost synonymously employed), before I
enter upon the description of the several varieties of defor¬
mities we have to consider. A little attention will enable
you to perceive that inflammation of the structures around
and within the articulations is the sole cause of this class
of affections. If we investigate the manner in which stiff¬
ness and deformity of a joint have occurred after accidental
injury, we find that the immediate effect of the injury was .
swelling and effusion of the part; or if a joint have be¬
come deformed from phlegmon, rheumatism, or scrofula,
these constitute but different forms of inflammation; and,
however various the progress of each, the mode of produc¬
tion of the deformity will be found very similar.

A more particular examination of the simplest case of
inflammation of the knee, which tends to deformity, ren-

* Celsus, lib. v. xviii. 28, states: “ ad recenti cicatrice contractos arti-
culos, quas ayictXas Grseei nominant, conveniens,” &c. Ankylosis has no
longer so limited a signification.

OR STIFF-JOINT.

ders clearer the manner in which immobility and shorten¬
ing of parts take place. Suppose an inflammation of the
knee from mechanical injury; this is combated by anti¬
phlogistic measures, the knee retaining the bent position.
At the expiration of weeks, or even months, according to
the general health and the propriety of the treatment, the
inflammatory symptoms subside without suppuration or
disorganisation; but the previous constitutional disturb¬
ance, the debility succeeding to antiphlogistic treatment,
and the experience of the exquisite pain and tenderness
which existed in the articulation, leave a morbid sensi¬
bility in the patient which strongly opposes any attempt
to straighten the limb. The inflammation may have sub¬
sided without producing disorganisation, but the interstitial
lymph has yet to be absorbed (p. 22), some thickening of
the tissues exists, the ligaments have not re-acquired their
extensibility, the muscles have adapted themselves to the
shortened state of repose; and whenever an attempt to
straighten the limb is made, or the patient summons reso¬
lution to effect the same, the tenderness which is imme¬
diately experienced, or the stiffness of the articulation
and the feeling of its powerless condition, often occasion
procrastination of this important part of the cure. If the
practitioner be seconded by the patient, the case proceeds
favourably, motion is daily augmented, the tenderness sub¬
sides, and the patient recovers. But when fear of repro¬
ducing inflammation by passive movements of the limb, or
the want of resolution to persevere in restorative measures
—frictions and manipulations—have occurred, or when the
inflammation of the joint has been very acute or of long
duration, and even the patient’s life has been endangered
by constitutional disturbance, the surgeon feels too happy
at having escaped imminent peril, and abandons the limb
for a time as a thing of inferior importance. Stiffness or im¬
mobility results. The deformity proceeds rapidly on the
destruction of the equilibrium in the muscles; and their-

PARTIAL ANKYLOSIS

retraction may not be arrested until the member is con¬
tracted to the full extent of its natural movements, and
sometimes even beyond them.

In persons under adult age the angularity of the limb
becomes augmented by the proportionally greater elonga¬
tion of the bones which occurs in a contracted limb during
the gradual growth of the frame at that period of life,
whilst the contracted state of the soft parts more com¬
pletely arrests their development.

In these instances of contraction from injury and in¬
flammation of articulations we can study the succession of
phenomena which have converted a healthy flexible joint
into a rigid immovable deformity. We recognise, in the
first place, the direct effect of the inflammation in stiffening
the soft parts; the swelling of those minute parts of which
the extra and intra-articular tissues are composed; and the
interstitial deposit of lymph, rendering them incapable of
immediately resuming their natural pliability. We per¬
ceive that the long-continued rest of the limb in one posi¬
tion is accompanied by shortening of the muscular struc¬
tures on the contracted side of the member. In the knee,
for example, the flexed or semi-flexed position is com¬
monly assumed; hence the continued approximation of
the origins and insertions of the flexor muscles induces a
gradual shortening of their fibres, in consequence of their
unceasing contractility. Their antagonists, the extensors,
are proportionately elongated, and ultimately their fibres
become weakened. . After some time the contraction (of
the flexors of the knee in deformity from inflammation of
the knee, for example,) attains the maximum, and is suc¬
ceeded by a change in the muscular fibre, which I have
already described under the name of structural shortening
(p. 13).

When inflammation of articulations is followed by sup¬
puration exterior to the synovial membrane, the granu¬
lations by which the cavity of the abscess is obliterated

FROM SCROFULA, RHEUMATISM.

afterwards constitute tough hands, approaching in density
to fibrous tissue. These gradually contract in a manner
similar to the contraction that takes place in cutaneous
cicatrices, and constitute an additional obstacle to restoring
the motions of the joint. The resistance these hands offer
will greatly depend on their direction. Should the sup¬
puration have been accompanied with loss of substance,
sloughing of the cellular tissue, fascia, or tendons, the
tendency to contraction and deformity will he proportion¬
ally stronger. Such are the modes in which partial an¬
kylosis and deformities are produced by common inflam¬
mation. I have now briefly to consider the influence of
scrofulous and rheumatic inflammation.

The strumous forms of disease usually differ from com¬
mon inflammation in the slowness of their course. The
contraction is very gradual; but as the disease affects young
subjects, the muscular retraction becomes ultimately as
unconquerable as in deformities from ordinary inflamma¬
tion. The limb is rarely so acutely flexed as after some
other causes of deformity, but contraction occurs in the
larger proportion of cases. Although suppuration some¬
times extends outwardly, accompanied with caries of the
bones, it is usually circumscribed, and does not induce
the extensive bands of dense adventitious tissue that suc¬
ceed to the suppuration of acute inflammation. The dis¬
organisation of the ligamentous structures being the com¬
mon result of this disease, partial luxation of the articular
surfaces often occurs, constituting a more complicated kind
of deformity.

Arthritic inflammation, under which head I include
rheumatism and gout, more frequently induces complete
immobility of the joint than any other disease. Greater
induration and rigidity of the articular tissues appear to
follow this than other inflammations, and considerable
proneness to calcareous or ossific deposit around and be¬
tween the articulating surfaces exists. Contraction and
deformity may occur as an immediate result of acute ar-

DISPLACEMENT OF ARTICULAR SURFACES.

thritis, or be a sequel of the chronic form of the disease,
years elapsing before the calcareous deposit acquires a
sufficient amount to render the joint quite immovable.
It is worthy of recollection, that the simple induration of
the tissues from rheumatism may suffice to produce com¬
plete immobility, without the existence of any ossific
union, and occasion an erroneous belief in the presence
of true ankylosis.

Many of the characters by which a deformity from
injury or disease is during lifetime recognised, may be
deduced from the preceding observations. The most im¬
portant is furnished by the history of the case, and by the
deformity having immediately succeeded the inflammation.
The most prominent symptom is the continued rigidity or
immobility of the joint, constituting, respectively, the cha¬
racteristic practical difference between false and true stiff-
joint. The distinction is often very difficult. In either
case the rigidity may be so great that no movement of the
articular surfaces is perceptible when the patient acts on
the muscles of the articulation, or when the endeavour is
made, by manipulation, to effect motion of the joint.

The deformity is often the result of displacement of
the articular surfaces, but sometimes depends on dispro¬
portionate development of the articular extremities, on
atrophy of one or more bones, or wasting of the muscles,
and is occasionally increased by the indented cicatrices of
former abscesses, caries, or necrosis. Shortening of the
muscles, tendons, ligaments, and fasciae situated on the
flexed surface of the limb exists in every case of stiff-
joint; but the muscular resistance to restoration is most
perceptible in false ankylosis.

In complete ankylosis the origins and insertions of the
contracted muscles cannot be separated by attempts to move
the joint, consequently no tension of their fibres can be
mechanically produced; but when incomplete ankylosis
exists, although extension be limited, the joint may remain
capable of greater flexion, so that the resistance offered by

DIAGNOSIS OF COMPLETE ANKYLOSIS.

the muscles is immediately apparent. Even in false anky¬
losis, where no motion is visible, and the absence of com¬
plete immobility is ascertained only by feeling very slight
movements of the articular surfaces, an alternate tension
and relaxation of the muscles may he produced by forcible
attempts to straighten and bend the limb. Muscular ten¬
sion is, however, a symptom of ankylosis which may occa¬
sion an erroneous diagnosis ; as, when absolute immobility
of one articulation exists, the patient may be able to act
through volition on those muscles which pass over two
joints (biceps femoris and gastrocnemii, for ex.), and occa¬
sion their alternate contraction and relaxation. As a means
of diagnosis, you will observe whether the muscular ten¬
sion he synchronous with your manual attempts to move
the joint. The amount of the resistance to restoration
afforded by the fascia and ligaments cannot always be
ascertained. The tension of those which are situated close
to the integuments,— as the fascia lata and the external
lateral ligament in the knee, or the palmar fascia in an-
kylosed fingers,— may be distinguished by the touch; but
we can only conjecture the degree of rigidity of those that
are immediately connected with many articulations, such
as the posterior and crucial ligaments of the knee-joint.
See p. 23 and Contracture.

The diagnosis of ankylosis from other affections of the
joints is not difficult. It is impossible to mistake, as has
been asserted, immobility from acute inflammation of an
articulation for stiff-joint; in the absence of constitutional
symptoms, the local tumefaction and effusion, with pro¬
bably an increase of temperature, would dissipate every
doubt.

The distinction of true from false ankylosis is often
difficult. The history of the case may assist your judg¬
ment. Where, for example, absolute immobility has suc¬
ceeded inflammation produced by mechanical violence, you
may often conclude that true ankylosis exists. The de-

LATENT INFLAMMATION

formity resulting from white swelling , on the contrary, is
usually incomplete ankylosis. Tact in the examination of
such cases will often enable you to detect mobility where
none was believed to exist, and to restore a limb that was
previously, from its uselessness, regarded as an incum¬
brance. The pain, or sense of tightness, on the flexed
side of the limb produced by manual attempts at straight¬
ening, is often an indication of the evidence of some mo¬
bility. But a much more delicate test is the production
of pain on the opposite side. I should warn you, how¬
ever, not to consider this test as infallible. Thus, two
instances of ankylosis of the knee have come under my
notice in which the patella was immovably attached to the
tibia by exostosis, or by ossification of the ligamentum
patellae. The attempt to straighten the limb induced pain
in front of the knee, either in consequence of the superior
edge of the patella being struck against the articular sur¬
face of the femur, or through the strain exercised on the
adventitious connecting bony matter. In a third case I
was unable to distinguish whether the patella was adhe¬
rent to the femur or the tibia. I have stated that a
patient who is affected with true ankylosis will permit
examination without apprehension; whereas in false an¬
kylosis the individual will mistrust manipulation. This
assertion is founded on the circumstance that pain cannot
be produced, in one case, by forcible attempts at straight¬
ening ; and that, in the other, a feeling of weakness in the
part, exists. Great reliance cannot always be placed on
this mode of diagnosis, for some patients labouring under
false ankylosis have as little apprehension of examination
as those who. are affected with true ankylosis, unless they
have already been subjected to painful investigation ; and
a nervous female would be very sensitive to impressions
whether she were affected with complete or with incom¬
plete stiff-joint.

I need scarcely mention that you should be quite cer-

A BARRIER TO TREATMENT OF ANKYLOSIS.

tain that no tenderness of the articulation from the previ¬
ous inflammation remains. A completely ankylosed limb
also conveys to _the hand of the examiner a sensation of
union throughout. The tibia and femur, in true ankylosis
of the knee, give the impression of a single bone; and
many of the patient’s sensations in the limb are referrible
to a want of elasticity, which is not absent in false anky¬
losis, even when no motion is visible. Thus, in true an¬
kylosis of the hip or the knee, the patient is more suscep¬
tible to shocks that are consequent on any sudden exer¬
tion. The whole frame may be jarred by an unexpected
false step. This is in great measure obviated by the flexi¬
bility of the ankle and powerful action of the gastrocnemii;
for, as in ankylosis of the hip or knee, the joint is usually
flexed, the patient is compelled to apply the toes only to
the ground, and the elasticity of the gastrocnemii may in
some degree compensate for the stiffness of the affected
joint.*

The prognosis of deformity from causes operating
directly on the joints (inflammation and disease) is, in the
great majority of instances, favourable. An opinion exists
that true ankylosis is not uncommon, whereas extended
observation shews that it is, comparatively, very rare.
On the examination of a doubtful case of deformity, it
is satisfactory to possess this preliminary information; for
although it may lead to error, you may be enabled to
undertake with more confidence a case which, but for
this circumstance, would be hopeless. Angular deformity
of a limb is more amenable to treatment than a fixed con¬
dition of the limb in a straight line, and is, fortunately,
the more common affection.

I shall in my next lecture speak of the treatment of
these deformities.

* Experience subsequent to the publication of the above views does not
enable me to add more certain rules for diagnosis. In obscure cases, exa¬
mination during anaesthesia is available (p. 43).

LECTURE III.

Treatment of deformities from injury and disease of articulations — Mani¬
pulations [with or without the aid of anaesthetics'] — Extension ly
mechanical apparatus—Division of tendons—Contracted hip from,
disease, with andwithout luxation of femur—True ankylosis of hip —
Co-existence of contracture of knee and ankle—Treatment of con¬
tracted hip — Section of tendons of the adductor muscles of thigh,
rectus femoris, fyc. — Value of operation — Contracted knee from
injury and disease — Complete and partial knee ankylosis, straight
and angular—Treatment of straight knee ankylosis—Prevention of
complete ankylosis.

The cure of these deformities (ankyloses) is accomplished
hy mechanical and chirurgical means, employed singly or
conjointly. A large proportion of cases being those in
which the rigidity depends on muscular contraction without
structural shortening, and with little adhesion of the tissues
on the flexed side of the joint, yield to the first class of
remedies. The simplest case of stiff-joint is that which,
for a few days or weeks, has been immovable after an ac¬
cidental injury, or from inflammation of the articulation,
without its termination in any disorganising process. Popu¬
lar practice, based on experience, consists in the energetic
and sedulous employment of frictions and passive move¬
ments, hy which the stiffness is gradually removed, volition
returns, and the part is restored to activity. In a higher
degree of rigidity the use of steam and vapour baths, olea¬
ginous embrocations, fomentations, shampooing, and the
application of mechanical instruments are required.

[These means, in many instances, are not rapidly fol¬
lowed hy adequate improvement, the obstacle varying in
different cases. Occasionally the inherent difficulty of the
case, or inappropriateness of the measures adopted, explains

EXPLANATION OF REPUTED DIFFICULTIES.

the want of favourable progress ; but I have, in consulta¬
tion, frequently observed that the impediment has resulted
from the excessive zeal of the practitioner and of those to
whom the functions of rubber, shampooer, and manipulator
have been entrusted; too great violence has been employed
from the outset; the system of the patient, either naturally
morbidly sensitive, or rendered sensitive by the sufferings
attendant upon the original disease, has been incapable of
supporting the too active efforts made for restoration. In
these instances, a gentle and patient application of the same
measures has been rewarded with success. In other cases,
in which the most favourable means have been recom¬
mended, the impediment to cure has proceeded from the
imperfect manner in which the manipulations and sham-
pooings have been effected. On recommending these pro¬
cesses in consultation, it not unfrequently happens that the
remark is made, that they have been already fruitlessly
tried; when, upon inquiry, it is ascertained that the so-
called manipulation or shampooing has been a mere surface
rubbing of the part, and not the really artistic proceeding
required for restoration. Therefore, if the manipulator be
found to be ignorant of the rude anatomy and functions of
the part, these must be taught him by the medical attend¬
ant. Some of the most remarkable instances of successful
empirical practice in the treatment of stiff-joints and con¬
tractures have been offered by individuals totally unac¬
quainted with the pathology of the cases they have under¬
taken to treat, but who, possessed of much sound common
sense and a few particles of anatomical knowledge, have
by manipulations and inunctions achieved the restoration
of members regarded as useless, incurable incumbrances by
able medical and surgical practitioners.

In cases obviously demanding more energetic proceed¬
ings, recourse may be had to the assistance of anaesthetics.
Under a state of partial insensibility induced by inhalation
of chloroform, a member obstinately resisting ordinary

CHLOROFORMIZATION IN STIFF-JOINT.

manipulations may often be made, by only moderately in¬
creased application of pressure and to-and-fro movements,
to yield to the fullest extent. The confidence inspired
by the knowledge obtained that the part was flexible and
extensible whilst under the influence of chloroform, induces
more successful exertions. Sometimes a moderate amount
of chloroformization may be repeated once or oftener ; in
other cases, more perfect anaesthesia may be induced for
the purpose of diagnosis and prognosis, the skilled hand
of the practitioner enabling him accurately to detect the
amount and nature of the resistance to cure. I have now
and then found it practicable to take advantage of the
straightening effected during the use of chloroform to se¬
cure the part in a suitable retentive apparatus. Usually,
however, in severe cases, the pain experienced in and about
the articulations after recovery of consciousness renders the
permanent employment of tight ligatures to maintain the
part in a new position intolerable (p. 43). I am unable to
speak favourably of the employment of sudden forcible,
violent extension of a member more or less completely
ankylosed during many years, with or without the aid of
anaesthetics. The reports circulated these two or three
years past to the contrary—of cures , in short, by these
means of long-standing ankylosis in the course of a day
or two—can have no existence in fact.*

The plan of M. Louvrier consists in placing the anky¬
losed limb, carefully padded, in a mechanical apparatus
possessing the powerful properties of the screw; by the
sudden and violent action of which, a limb, that may have
been many years rigidly ankylosed, is in the course of a
few seconds straightened, apparently regardless of rupture
of tendons, nerves, and blood-vessels.

* The following extracts from the preface of the author’s treatise on An¬
kylosis or Stiff-joint (Longmans, 184S) will explain the nature of the “ vio¬
lent method of extension,” originally introduced by Louvrier of Paris, and
said to be revived since the discovery of chloroformization.

EVILS OF SUDDEN FORCIBLE EXTENSION.

In Dieffenbach’s plan of treating knee-ankylosis, the
patient lying on his stomach, and the knee projecting be¬
yond the edge of the table, the resisting tendons are divided
subcutaneously; the operator then bends the knee so power¬
fully as to bring the heel in contact with the nates. He
then moves the limb in the opposite direction, and extends
it more and more forcibly, occasionally reverting to flexion,
and continues this motion of the limb up and down until
it is straight. Dieffenbach states^ that he has often found
the united force of three or four men necessary, particu¬
larly in adult cases, “ to break a knee straight .”

In condemnation of proceedings so dangerous, the ani¬
madversions formerly published by the author,-j- on a simi¬
lar practice of Sartorius in relation to club-foot, may be
consulted. The methods of Louvrier and Dieffenbach are
equally inapplicable. Some strictures thereon, contained
in a recent review J of Dieffenbach’s treatise, are entitled
to serious perusal by those who may contemplate resorting
to this summary mode of proceeding.

* Ueber die DurcJischneidung der MusJceln und Sehnen. Berlin, 1841.

f Treatise on Club-Foot and analogous Distortions, Introduction, p. xlix.

t “ Louvrier’s violence snaps tendons, tears old adhesions, fasciae, and
ligaments, violently stretches when it fails to lacerate nerves or rupture blood¬
vessels^ yet were some or all of these results to take place, provided the skin
is not torn and an external wound produced, the patient has a better chance
of recovery than when Dieffenbach, in deference to the tendons, divides them
with the knife, leaving one or more punctures. We should sooner anticipate
laceration of the skin when a puncture, however small, is made, as that may
serve as a point from whence a rent may commence, or inflammation, sup¬
puration, and gangrene take their origin. No increased danger can result
from Louvrier undertaking to rupture tendons as well as other tissues. The
rupture of the tendo achillis is comparatively a trifling accident; and if the
rupture of the ham-strings was the limit of Louvrier’s violence, we should
not so mubh condemn him: but the danger in reality arises from the injury
inflicted on the large nerves and vessels of the popliteal region; and if the
sudden forcible straightening of the limb be accomplished, this injury must be
equally great whether resistance of the tendons has been previously removed
by division or not .”—British and Foreign Medical Review, January 1842,
p. 16. W. J. L.

62 MILD MEASURES MORE SUCCESSFUL.

llupture of the popliteal artery, laceration of the sacro-
sciatic nerve and other textures, with the attendant deplor¬
able consequences, occurred in several instances on the ap¬
plication of the sudden forcible straightening by Dieffen-
bach and Louvrier. These results sufficiently attest the
danger of the great degree of violence to which they re¬
sorted.

The following pages demonstrate the possibility of
straightening every case of incomplete angular knee-anky¬
losis, even after twenty-six years’ duration of deformity;
it is therefore probable that Dieffenbach’s former want of
success was attributable to insufficient attention to the me¬
chanical treatment after the section of tendons. A careful
comparison of the length of time during which mechanical
treatment was required, even in Dieffenbach’s successful
cases of the application of the violent sudden method , with
the period of time occupied in the treatment by the method
of gradual extension , shews that Dieffenbach’s plan has not
the merit of effecting rapid restoration.

Although in Dieffenbach’s successful cases the limbs
were by violence suddenly straightened after subcutaneous
division of tendons, the resulting inflammation (in some
proceeding to suppuration and sloughing of integuments)
and constitutional disturbance prevented the proper and
continued application of apparatus for the maintenance of
the parts in the straight position. This part of the treat¬
ment, important to the success of even the violent method,
having necessarily been neglected, a strong tendency to
recurrence of ankylosis was evinced, requiring, after all,
the application of the gradual method of extension. In
this manner the entire treatment occupied as long a period
as usually suffices to effect restoration by the Stromeyerian
plan, viz. subcutaneous tenotomy, succeeded by gradual
extension.]

Where the immobility and contraction are considerable

STAGES OF THE TREATMENT.

and of long duration, have resisted proper mechanical ap¬
pliances, and principally or greatly depend on muscular
shortening, we may have recourse to section of the ten¬
dons of the contracted muscles and ligaments, and of those
hands of fascia and adventitious tissue which are within
easy reach of the scalpel, followed by the application of
appropriate mechanical apparatus, frictions, and manipu¬
lations. In the operation, the Stromeyerian method, viz.
that of subcutaneous section, should be followed, and
the limb be suffered to remain at rest in the deformed
position until the small punctures have cicatrised. The
limb should then be gradually extended, or flexed, as the
case may require; the progress of this part of the treat¬
ment being slow or rapid, according to the size of the
joint, and the dependence of the resistance to restoration,
on the superficial situation, or the depth of the tissues
around the articulation. The time requisite to effect a
cure varies from one week to six months; occasionally a
much longer period elapses before the articulation entirely
resumes its functions.

When tenotomy is employed, the combined treatment
may be divided into three stages: the section of tendons,
the mechanical reduction of the deformity, and the period
employed in restoring free movement by passive and active
exercises, frictions, manipulations, baths, &c. The first
and second stages usually engage but little time; the last,
which is commonly the longest in duration, becomes often
very tedious.

The treatment requires, even under the most favourable
circumstances, great care and perseverance ; and its accom¬
plishment in some instances is so tedious and difficult as
to discourage those who are not endowed with remarkable
patience. I must, therefore, impress upon you the im¬
portance of steadily pursuing the means you have selected,
so long as gradual amendment in the position of the part
is observable. You may, occasionally, after uninterrupted

DEFORMITY FROM CALLUS.

progress, suddenly meet with an obstacle to further straight¬
ening. A careful examination of the member becomes
essential; you may discover some fibrous or tendinous
hand, the section of which may be necessary, or you may
detect an insurmountable obstruction to complete restora¬
tion in the presence of some osseous or other firm adven¬
titious deposit. The time during which an articulation
may have been in part or wholly immovable, and yet be
capable of restoration, appears sometimes incredible. The
removal of deformity of that most important articulation
the knee, which had existed twenty-six years, has been
effected. Restoration after ten and fifteen years’ loss of
the use of an articulation is not uncommon.

True ankylosis, or osseous union of the articular sur¬
faces, having been regarded as a fortunate termination of
articular disease, has rarely been the subject of curative at¬
tempts. The most notable and ingenious of these is the
relief, by Dr. Barton of Philadelphia, of true ankylosis of
the hip, by sawing through the neck of the femur, and,
after obtaining closure of the external wound, resorting to
daily movement of the limb, so as to produce, at the un¬
united parts of the bone, an artificial joint. This operation,
in Dr. Barton’s case, succeeded perfectly; in the hands of
other practitioners, it has been alternately successful and
fatal. It is preferable, in my opinion, to that proposed for
true ankylosis of the knee by my friend Professor Dieffen-
bach of Berlin, namely, breaking down the osseous union
by chisel and mallet.

[Paulus iEgineta and Celsus had already recommended
similar rude and dangerous means for the removal of de¬
formity from redundant callus, p. 40.]

I entertain no doubt of the capability, in some instances,
of restoring motion in an articulation between the surfaces
of which the deposit of calcareous particles has already
commenced. Nevertheless, the risk of reproducing disease
will, for the most part, preclude the attempt.

LAMENESS FROM HIP-JOINT DISEASE.

On Deformity from Ankylosis of the Hip.

Inflammation of the hip-joint, acute and chronic, may¬
be induced by cold, mechanical injury—a blow or a fall on
the part; or it may be a sequela of typhus, scarlatina, and
variola, or other general disturbance of the health. Rheu¬
matism is an occasional cause; but more commonly the
inflammation partakes of that specific character which is
denominated strumous. By whichsoever cause the inflam¬
mation is produced, deformity is not an unfrequerit termi¬
nation of it. The most frequent and the most simple form
is that of false ankylosis of the hip, without luxation. The
stiffness or rigidity may be slight, depending only on some
thickening of the capsular ligament, and on rigidity of the
muscular tissues, from repose of the articulation. Lymph
may have been effused into the interior, or upon the exte¬
rior of the articulation, constituting unnatural adhesions;
suppuration may have proceeded externally, the route of
the pus being indicated by firm bands, and cicatrices,
which more completely obstruct the motion of the mem¬
ber. Each of the above causes may
induce stiffness, immobility, deformity,
and lameness, in consequence of the
temporary disuse of the joint being
attended by structural shortening of
the muscles.

The symptoms are these: — The
thigh is rigidly flexed and adducted,
and consequently the patient can effect
but slight or no involuntary movement
of the joint; the trochanter major re¬
mains in its natural position; and con¬
siderable flattening of the nates, from
wasting of the glutsei, exists; with Incomplete ankylosis from
tension of the adductor longus, the
adductor brevis, the adductor magnus, the pectineus, rec¬
tus femoris, and, occasionally, the sartorius and gracilis

DIAGNOSIS OF HIP-LAMENESS.

muscles. Little or no motion of the head of the femur in
the acetabulum is perceptible on manipulation. With the
duration of the ankylosis, the knee becomes more approxi¬
mated to the abdomen and to the opposite member. The
patient applies the toes only to the ground, and walks with
considerable lameness.*

* The larger number of cases of hip deformity which have, during the last
fifteen years, come under my notice, have resulted from ordinary disease of
the hip-joint, which had not been detected during the earliest stage. I have
also been consulted in many cases of incipient hip-disease, which have been
regarded as cases of “ lameness” from a trivial cause, the surgical attendant
having failed to attribute the lameness to the right cause. I know not whe¬
ther the early stage of this complaint more often escapes recognition than
the early stage of other and especially internal diseases; but from the fre¬
quency with which even good surgeons have overlooked it, I suspect that in
some minds uncertainty as to its diagnosis exists. It would be foreign to
the subject of deformity to enter fully in this place into the signs by which
the earliest stage of hip-disease may be distinguished ; I may, however, be
permitted briefly to state the result of my experience.

The only forms of “ lameness” the symptoms of which in any degree re¬
semble those of incipient hip-disease, are, 1, incipient psoas abscess; 2, slight
paralysis of some of the muscles of hip and other parts of the lower extremi¬
ties; 3, spastic affection of hip and other muscles; 4, incipient disease of
knee; and 5, certain cases of contracted gastrocnemii.* In all of these cases,
some resemblance to incipient hip-disease, as respects the mode of walking,
the position of the thigh, and the form of the hip, exists. The cases num¬
bered 4 and 5 may be passed over, as an adequate examination of the knee
and ankle joints suffices to shew that the cause of the lameness resides exclu¬
sively in those articulations. Cases 2 and 3, although usually presenting some
. flattening of the nates, with flexion and adduction of thigh,— and 3 presents
even a stiffness of the hip similar to the partial immobility of the part in hip-dis¬
eases,— may be distinguished by the signs of paralysis or spastic action more
or less slight in other parts of the member. Hip-lameness from incipient
psoas abscess is the only case that may justifiably be confounded with incipi¬
ent hip-disease ; for the disturbed augmented action of the psose, which effects
a constant drawing up of the thigh, with disuse of the part, consequent flatten¬
ing of the nates, wasting of the member, prominence of the articulation of hip
and trochanter, give a very deceptive appearance of hip-disease, when spinal
curvature is not present to account for the psoas disease.

* Congenital luxation of hip should not, in the absence of any history of the case, be
confounded with incipient hip-disease, for the abnormal position and development of the
trochanter, which exist in congenital luxation, are absent in incipient hip-disease.

SYMPTOMS OF ORDINARY HIP-ANKYLOSIS.

False ankylosis of the hip, with luxation , comes next in
order of description. In many cases the ligaments by which
the head and neck of the thigh-bone are attached to the
acetabulum become disorganised and loosened ; the rim of
the acetabulum and part of the head of the femur may
have been destroyed by ulceration and caries, and tbe femur
having been thus left to the unresisted action of the muscles
of the hip, has become luxated, and is found resting either
on the ilium, or in the isehiatic foramen. In either of
those situations the process denominated the “ formation
of a new joint” sometimes ensues; but whether so great
natural efforts at reparation take place or not, much ri¬
gidity, muscular shortening, and
distortion remain.

The symptoms of this last-
described condition are, rigid
flexion and adduction of the
thigh, immobility, atrophy, and
tension of muscles (greater than
in the simple form of false an¬
kylosis), and the trochanter is
less prominent, and is situated
at a greater distance from the
anterior superior spine of the
ilium than natural; the thigh
is shortened by elevation of the
femur upon the dorsum ilii, or
upon the edge of the saero-scia-
tic foramen, and by the caries
or absorption of the head of the
bone, producing considerable
deformity ; the leg . and foot
are rarely so large as the cor¬
responding parts in the SOUnd angular ankylosis of U v .

limb, their development having been impeded by long
rest of the limb during the articular disease which pro-

FALSE AND TRUE HIP-ANKYLOSIS.

duced the deformity. The diminution in length of the
member, arising from these causes, may vary from half an
inch to five inches, locomotion being effected with the
assistance of a boot, the sole or heel of which is raised to
a proportionate thickness; or the flexion of the thigh may
be extreme, and, by preventing the application of the foot
to the ground, may compel the patient to use a crutch*
See fig. 9.

As for true ankylosis of the hip — deformity from com¬
plete or osseous union between the articular surfaces,—it
so rarely ensues before the age of puberty, and is, conse¬
quently, so seldom the subject of consultation, that with¬
out the existence, in pathological museums, of preparations
demonstrating it, the practitioner might almost doubt its
occurrence. True ankylosis may be simple, the head of
the femur remaining in the acetabulum, which is uncom¬
mon ; or it may be compound, the head of the bone being
luxated, which is the common form. True simple anky¬
losis may be angular or straight; that is, the limb may
be fixed either in the flexed or the extended position;
whereas in true ankylosis with luxation, it is always angu¬
lar, the limb being fixed in the semi-flexed position.

Symptoms of deformity from true ankylosis of the hip,
with luxation, are, as regards the position and form of the
limb, precisely similar to those of false ankylosis with lux¬
ation, the difference consisting in the absolute immobility
of the thigh. The diagnosis is often extremely difficult;
for in false ankylosis,— owing to the great degree of mus¬
cular tension and the rigidity arising from deposition of
lymph or cicatrices—mobility of the femur can, in some
cases, be detected only after repeated examination, and
often not until the pelvis has been firmly fixed by an able
assistant. The alleviation of the inconvenience of anky¬
losis of the hip depends on the existence of mobility,
however slight; the importance of a correct diagnosis can¬
not, therefore, be too highly estimated. In some cases

TREATMENT AFTER HIP-DISEASE.

considerable tact and experience in examination are re¬
quisite.

In every form of deformity from ankylosis of the hip,
contracture of the corresponding knee and ankle may co¬
exist ; and if the deformity be wholly or partially remedi¬
able, the contracture of these parts will require separate
treatment.

Treatment . ■—If, in chronic or acute inflammation of
the hip, the practitioner has been so successful that, after
a few weeks’ or months’ duration of the disease resolu¬
tion has been effected, and slight muscular contraction,
with thickening of the articular tissues, alone remains,
attention to manipulation, friction and extension of the
limb, with cautious exercise, may restore the functions of
the member. If the muscular, contraction and other re¬
sistance canno.t be overcome by these means, an apparatus
consisting of a circular bandage fastened to the pelvis, and
sometimes to the shoulders, with a steel spring [gun-lock
or ratchet-screw] attached to the femur, in order to effect
extension of the member, may be worn, and will, in a
short time, sufficiently remove the contraction to permit
the application of the foot to the ground. Or the same
object may be attained by lightly bandaging a tin [leather,
gutta percha] or wooden splint behind the hip and thigh
during a portion of the day, or during the night.* Should
the use of apparatus and frictions prove insufficient, the
division of the contracted muscles offers a remaining chance
of restoration; but that should not be resorted to until the
practitioner is satisfied that no risk of reproducing the dis¬
ease of the hip exists. Thus within the first, second, or
third year of the cessation of the hip-joint disease, the
attempt at restoration by means of mechanical apparatus
will usually be preferable ; and if in this manner the mem-

* An instrument is manufactured by Ferguson, Giltspur Street, which
effects in a superior manner the triple object of extension, abduction, and
rotation outwardly of the thigh.

TREATMENT AFTER HIP-DISEASE.

ber cannot be completely straightened, the aggravation of
its position will be prevented. Even when osseous union
appears to be imminent, judicious recourse to mechanical
means will place the femur in such a position that the
deformity will be much diminished, and the member will
prove much more serviceable than when, from ignorance
of the value of attention to that circumstance, the limb is
permitted to remain in the completely flexed position.
The section of some of the contracted muscles already
enumerated is of value in false ankylosis of the hip, even
when many years have elapsed since the original disease
began. I have by this means successfully treated adults
who had suffered from morbus coxarius in their infancy.

The prognosis must, however, be guarded; for owing
to the anatomical conformation of the hip, greater difficulty
in ascertaining the precise change which the structures
have undergone exists than in similar deformity of many
other articulations. Excepting in children, the flexion of
the hip cannot be entirely overcome; but if, in older per¬
sons, restoration can be so far effected by the aid of teno¬
tomy that, instead of walking with a crutch or crutches,
and having the knee drawn up to the abdomen, the thigh
can be straightened to the extent of permitting partial
application of the foot to the ground, you will be amply
rewarded for the attention bestowed on a case of a not
very encouraging nature.

I recommend the operation to your attention less as a
curative plan than as an important means of amelioration
[in extreme cases]. Remember, however, that when you
may have satisfactorily performed the section of tendons,
the least difficult part of the treatment will have been ac¬
complished. In hip cases of deformity, indeed, as in every
other, especial attention to the after-treatment is indis¬
pensable. Arrange beforehand the means that seem to be
necessary for restoring the form and mobility of the part,
and, after cicatrisation of the punctures, suffer no delay

KNEE-ANKYLOSIS.

in the application of those means. Here is a cast of a
late in-patient (fig. 9), aged sixteen years, in whom the
limb was elevated to such an extent that the knee almost
touched the abdomen, locomotion having been effected on
crutches. The ineffectual application of mechanical ap¬
paratus in this case induced me to recommend tenotomy,
from which sufficient amendment resulted to permit the
application of the foot to the ground with the intervention
of a sole two inches thick.*

I shall conclude this part of the lecture with two cau¬
tions : first, beware of using violence in the after-treat¬
ment ; secondly, avoid tenotomy, or even active manipula¬
tions, until the original disease and any tendency to relapse
have completely subsided.

I now proceed to the subject of

Contracted Knee, from Inflammation or Disease of
the Articulation.

The great size of the articulation of the knee, the large
amount of lowly-organised fibrous tissue entering into its
composition, the absence of warm muscular coverings, such
as are present in the shoulder and hip-joints, and its con¬
sequent greater exposure to changes of temperature, its
distance from the central organ of the circulation, and the
dependent position of the lower extremity, together with
its liability to accidental injury, explain its susceptibility
to disease. The knee is, in fact, more obnoxious to the
destructive influences of scrofulous, rheumatic, and other

* Having met with several cases of complete straight hip ankylosis, and
noticed the comparatively greater facility of locomotion possessed in such
cases than when complete ankylosis occurs in the extremely flexed position,
as at fig. 9, I have formed the opinion that it would be safe, practicable, and
advantageous, in angular hip ankylosis, to divide the femur near to the pelvis,
and by gradual depression of the thigh obtain union of the bones at such an
angle as would suffice for application of the entire sole to the ground. Short¬
ening of the limb would require the compensation of a raised shoe.

KNEE-ANKYLOSIS IN STRAIGHT POSITION.

inflammations, than any other articulation of the frame,
and consequently the contraction and deformity denomi¬
nated stiff-joint is of frequent occurrence in this situation.

Knee ankylosis may be of two kinds; complete or
osseous, and partial or membranous. The former, being
insusceptible of any relief, except when the calcareous
spiculse are very few, need not detain us long. Greater
importance attaches to the consideration of the means of
distinguishing true from false ankylosis.

Little or no deformity accompanies partial straight an¬
kylosis of the knee, except that arising from imperfect de¬
velopment or wasting of the muscles of the thigh. These
offer occasionally a strong contrast with the powerful mass
of the gastrocnemii, the energy and growth of which have
been excited by the increased demands on their activity
consequent on the stiffness of the knee. The leg com¬
monly presents slight rotation outwardly, the toes being
everted. In the act of walking, therefore, the foot more
easily avoids inequalities on the surface of the ground.

Straight partial ankylosis of knee is sometimes the result
of imperfect cure of angular ankylosis, extension having
been accomplished, but the joint remaining incapable of
flexion. You may, therefore, be consulted in a case of
rigid immovable knee in the straight position, and be re¬
quired to consider the propriety and possibility of restoring
the natural movement. You will reflect on the probable
nature of the obstruction; you will endeavour to ascertain
whether it arise from adhesions resulting from effusion of
lymph among the extra-articular tissues, whether from
bands of adventitious matter, the product of cicatrised
abscesses, or from membranous and calcareous adhesions
of the opposing articular surfaces. You will refer to
your knowledge of morbid anatomy derivable from ana¬
tomical museums ; and remember the possibility of bony
matter being deposited in the posterior part of the joint,
in the situation of the crucial ligament, or perhaps the

PREVENTION OF KNEE-ANKYLOSIS.

patella being ossified to the femur, so as to restrain the
movement. When satisfied of the existence of mobility,
however slight, especially when the resistance is of an
elastic nature, you will employ the general therapeutic
measures described whilst treating of deformities from anky¬
losis in general,—frictions, manipulations, bathing,—and
for mechanical means select one of the forms of apparatus
I shall recommend for reduction of angular deformity,
the action of the instrument being of course reversed
when you desire to bend the articulation. I have not
found the aid of tenotomy requisite in the remediable
cases of a straight stiff knee that have fallen under my
observation. Although this deformity does not prevent
application of the foot to the ground, it occasions great in¬
convenience in walking upon an uneven surface, or ascend¬
ing a hill or staircase. The great flexibility of the ankle,
to a certain extent, relieves the discomfort; but the limb
being, from the inflexibility of its most important joint,
rendered relatively too long, it is felt continually in the
way ,—patients eagerly embrace the hope of obtaining a
slight amount of flexion; and this may, in the majority
of instances, be obtained by perseverance in the methods
above mentioned.

I may add a few remarks here on the prevention of
ankylosis and deformity. Many cases will present them¬
selves, in which, after inflammation, either of a phleg¬
monous or a rheumatic character, and incipient calcareous
deposit, attention may be usefully directed to attaining a
more favourable position of the member, and to the re¬
tention of a limited amount of mobility. Bear in mind
that a slightly flexed knee is preferable to an absolutely
straight one, and that even mobility to the extent of a
few degrees will greatly ameliorate the patient’s condi¬
tion.* Surgeons entertain well-founded objections to the

* The author has here omitted a paragraph in which interference with
incipient ossification was recommended (p. 64).

OPPORTUNITY OF TREATMENT.

movement of a recently inflamed articulation as a means
of preventing stiff-joint, the danger of reproducing dis¬
ease being, in incautious hands, great; but too limited a
view of the nature of the previous disease, and exagge¬
rated fears of the danger of relapse, often indispose the
practitioner to attempt restorative measures. Remember,
however, that most local inflammatory affections require
for their production and maintenance a morbid condition
of the general frame, and that, during the continuance of
the local disease, a beneficial change in the general health
often ensues; so that those means which, at one stage of
the affection, would have been ruinous to the articulation,
may at another be safely applied. The general health
should constitute an important guide in the endeavour to
restore flexibility to a partially ankylosed limb. After
severe inflammation of a joint, which has not terminated
by resolution, but by one or other of the “ terminations
of inflammation,” the system having been depleted, or the
morbid predisposition removed [by time], by proper regi¬
men, or by antiphlogistic and other remedial agents, we
may usually, within a few months, endeavour to remove
the resulting rigidity; but after strumous disease of an
articulation it is prudent to wait a longer period, or until
a favourable change in the diathesis of the individual has
taken place. Sometimes, in such cases, we may be com¬
pelled to wait even several years before attempting to
restore the usefulness of the member.

LECTURE IV.

Contracted knee from disease, or angular knee ankylosis—Varieties —
Mode of distinguishing remediable from irremediable cases — Com¬
plication of contraction of knee with displacement of articular sur¬
faces — Treatment: mechanical means; section of ham-strings, fyc.

Angular contraction and deformity of the knee (false an¬
gular ankylosis) is the more frequent result of disease of
the articulation, and presents itself in numerous grades of
severity. The articulation may, from the previous disease,
have undergone the smallest appreciable injury in structure
and function; or the greatest amount of disorganisation,

Front and lateral views of knee-ankylosis from chronic ( scrofulous) dis¬
ease, excited by general debility consequent on an attack of fever.

INCOMPLETE KNEE-ANKYLOSIS.

ulceration, adhesions, cicatrices, and luxation, compatible
with remaining motion, may exist. The contraction may
vary from a few degrees, the sole being scarcely raised from
the ground (figs. 10 and 11); or it may be so considerable
that the heel almost
touches the nates (fig.
12). Locomotion is
frequently in such
cases impossible, ex¬
cepting with the aid
of a crutch and stick,
or a raised shoe.

The muscular short¬
ening corresponds with
the contraction. The
tendons of the biceps
and semi - membrano-
sus and semi-tendino-
sus muscles are tense
when extension is at¬
tempted. Sometimes
the biceps appears a-
lone contracted; but,
in such cases, section of
the inner ham-strings
is usually necessary to
complete the restora¬
tion. In false angu¬
lar ankylosis of many
years’ duration, the lower portion of the vastus externus,
and the portion of the fascia lata with which it is con¬
nected, and even the sartorius and gracilis tendons, are
much contracted.

Emaciation and wasting of the bones accompany every
[long-standing] case of angular knee-ankylosis. Occasion¬
ally, some contraction of the gastrocnemii, and other pos-

Fig. 12.

nous erysipelas of entire limb, completely straight¬
ened and restored to active usefulness after section
of ham-strings, %c.

MODE OF EXAMINING KNEE-ANKYLOSIS.

terior muscles of tlie leg, coexists. The degree of motion
remaining is variable; in some cases in which the contrac¬
tion habitually amounts to 70° or 90°, the limb admits of
slow extension by pressure, and reduction of the contraction
20° or 30°. The kind of resistance felt on attempting to
make extension may be termed elastic. Sometimes free
motion within a limited range exists, a sudden stop to fur¬
ther movement being perceptible. Occasionally the knee
cannot be extended beyond a right angle, but freely admits
flexion, so that the heel may be approximated to the nates.
In many cases, however, there is no perceptible flexion or
extension, the joint being truly stiff: here the question of
the existence of true ankylosis arises. The absence of
osseous union between the tibia and femur, or between
the patella and either of those bones, can only be deter¬
mined by the most accurate investigation. If the patella
be free, or merely united by membranous or ligamentous
tissues, some slight motion on its perpendicular axis may
be discovered; one of its edges, more commonly the inner,
may be depressed. A slight movement of the edges of the
tibia and femur where they are applied to each other may
sometimes be felt.

In addition to these means, you will observe whether,
on endeavouring to extend the limb, the ham-string muscles
be rendered tense. Caution is necessary when resorting
to this source of diagnosis, lest the voluntary tension of
the muscles by the patient be mistaken for that maintained
by the attempt to straighten the limb. The patient’s
mind should be diverted during the examination ; and
you should observe whether the tension and relaxation
of the tendons be really produced by the alternate exten¬
sion and relaxation of the limb effected by your hand. I
have already alluded to the production of pain on the con¬
tracted and uncontracted sides of the member, and the
relative value of the information derived therefrom (Lec¬
ture II., p. 55). The external configuration of the knee in
angular ankylosis varies; the joint may be rigidly flexed,

KNEE-ANKYLOSIS, WITH DISPLACEMENT.

the form not differing from that of the sound knee simi¬
larly flexed. This often occurs in cases resulting from
phlegmon affecting the entire limb (as at fig. 12), or after
rheumatic inflammation of the joint; whereas, in other
instances, especially after strumous and other forms of
synovitis, in which softening and disorganisation of liga¬
ments have taken place, the muscles have not simply con¬
tracted the articulation, but they have likewise altered
the relation of the articular surfaces, and occasioned partial
luxation and deformity, as in these models (figs. 10 and 11).

Fig. i 3 . The displacement in¬

variably consists of a
dragging backward of the
head of the tibia from the
anterior and inferior part
of the articulating surface
of the condyles of the fe¬
mur by the continued ac¬
tion of the ham-string
muscles, and is increased
by the rotation outwardly
of the head of the tibia, ef¬
fected by the more power¬
ful action of the biceps,
favoured probably by the
peculiar arrangement of
the crucial ligaments, and
sometimes by the patient,
during the articular dis¬
ease, havingreclined on the
back whilst the limb was
placed on the outer side.
This outward rotation of
the tibia is accompanied
with eversion of the leg.
The patella and its li¬
gament are abnormally

TREATMENT.

placed on the external condyle (e c, e c, fig. 13). .The con¬
joint phenomenon of displace¬
ment, rotation, and eversion of
tibia exists in different degrees;
it may be slight, or almost com¬
plete dislocation of the tibia may
be present, and even the anterior
surface of the tibia may be ap¬
plied to the posterior part of the-
femoral condyles, and the utmost
deformity result, as in this model
(fig. 14).

The great majority of cases of

false ankylosis of the knee are un- Angular incomplete knee-ankylosis
. . . , . „ from vMte swelling.

accompanied with pain. It, there¬
fore, pain be constantly present, or if, after exercise, some
part of the articulation be painful, particularly if the case
be not complicated with displacement, we may suspect
that the original disease of the articulation has not subsided.
But if displacement exist, and pain on the inner side of
the articulation be experienced only after unusual exertion,
and it subside after moderate rest, without application of
remedies, we may infer that it is merely the result of an
undue straining of the ligamentous structures of the part,
consequent on the weight of the body being inefficiently
borne by the contracted limb, and its having a tendency
gradually to produce a further displacement.

Treatment of angular knee-ankylosis. —When, from the
existence of mobility, the absence of disease of the articu¬
lation, or other insuperable obstacle, you may have de¬
termined the remediableness of a case of false ankylosis,
you will then decide on the propriety of confiding to me¬
chanical means, or of resorting to surgical operations. I
have already,- in the remarks on the treatment of ankylosis,
indicated the principles on which the treatment should be

TREATMENT.

conducted. The apparatus which I have found serviceable
under such circumstances is a common splint, bandaged on
the contracted side of the articulation during the intervals
of the manipulations, frictions, and baths; or if the flexion
of the limb prevent the application of a perfectly straight
splint, each of a series of tin splints, at different angles,
may be successively employed, until the limb is perfectly
straightened. A very common and excellent contrivance
consists of two wooden or metal splints, adapted to the
posterior surface of the thigh and leg, connected behind
by an ordinary male and female screw [or laterally by a
ratchet-wheel], by means of which the joint may be gra¬
dually extended, or [in extreme cases] the more complex
apparatus (fig. 15 or 16) may be used.

It consists of a a, mahogany board; l b, movable padded metal pieces, and

c, laced circular bandage, serving to encase and fix the thigh and pelvis ;

d, laced stocking and straps, secured to the screw m, constituting the
means by which the foot is drawn downwards, and the articular extremi¬
ties of knee drawn asunder ; /, concave pad, serving, through the agency
of o, to press down the knee; e, movable pad, attached to a movable screw,
adapted so as to press the fibula and tibia inwardly; g, similar pad, to
press the internal condyle outwardly; h, one of a pair of uprights, on
which rests transverse piece i, serving as a bridge, from which, by means
of the strap k, the upper portion of the tibia is elevated; l, a spring, the
action of which inverts the foot, and combined with m, inverts the leg.*

* See value of gentle mode of proceeding, pp. 38, 39, especially appli¬
cable during the employment of powerful apparatus.

DIVISION OF TENDONS FOR KNEE-ANKYLOSIS. 8!

When, however, the rigidity is very considerable, the
deformity having existed during several years, and me¬
chanical means offer no prospect of cure, the propriety
of resorting to tenotomy should be considered. The parts
that may require division are the tendons of the biceps,
semi-membranosus, semi-tendinosus muscles, the lower por-

Fi 3-Apparatus for effecting exten¬
sion of the knee. It consists
of a firm steel bar, extending,
on both sides of the limb,
from pelvis to the sole, with
joints at knee and ankle, the
thigh and leg pieces being ca¬
pable of elongation by means
of the sliding pieces and screws
//, e e. The part i indicates
the padded upper extremity
of the apparatus, adapted for
pressure against pelvis ; g g,
straps to which an ankle-piece
may be secured for the pur¬
pose of holding down the
heel; h, series of straps, in¬
tended to secure foot in shoe;
c, an ordinary male and fe¬
male screw, by turning of
which straightening of the
knee is effected; d, concave
pad, which, by turning the
screw b, may be made to
press the upper part of the
fibula and tibia inwardly; a,
similar pad, which, by the
action of a screw on corresponding side of apparatus, effects pressure against
the internal condyle. When the affected limb is properly secured, the articular
extremities of femur and tibia may be separated as described page 85, by
the gradual operation of the screws//, e e. A padded knee-cap, to prevent
elevation of the knee, completes the apparatus.*

* Where only a moderate resistance has to be overcome, the extension
may be effected by a ratchet-wheel action instead of the male and female
screw.

TENDONS TO BE SEVERED.

tion of the fibres of the vastus externus muscle, and the
fascia above it; and some bands of fascia in the popliteal
region do not escape division. Occasionally, section of
the sartorius and gracilis tendons will assist the restoration
of the limb. The necessity of each or all of these sections
should be determined from the existence of such an amount
of tension in each of the tissues as would greatly or insu¬
perably oppose mechanical elongation.*

Should an old, firm, indented cicatrix appear, by its
adhesion to the bone beneath, to he capable of offering
resistance to the extension of the limb, its deeper attach¬
ment may, if practicable, be subcutaneously divided.

The operation, when properly conducted, is followed
by no pain or febrile disturbance ; the punctures cicatrise
on the third or fourth day, being a day or two later than
when tenotomy is practised in the foot, probably in con¬
sequence of the greater laxity and abundance of the cel¬
lular tissue in the popliteal region.

[The method of dividing the ham-string tendons is
very simple. The patient should be placed in the prone
position, and the limb firmly extended by an assistant, in
order to render the parts sufficiently tense. The tenotome
should be introduced flatly through the integuments on
the internal edge of the tendon to be divided as deeply as
may appear needful for passing around it. When the in¬
strument is known to be situated between the tendon and
the more deeply seated structures, the edge should be
turned towards the tendon; cutting it, therefore, in a di¬
rection from the deeper structures of the limb towards the
surface. As the outer ham-string is often more tense than
the inner, it will usually be found advantageous to com¬
mence with the biceps, and proceed afterwards to the semi¬
membranosus and tendinosus ; for the division of the biceps

* I have here omitted some observations which tended to justify divisions
of superficial nervous filaments in the ham ; a proceeding which later expe¬
rience does not sanction.

MODE OF DIVIDING HAM-STRINGS.

causes the remaining muscles to become more prominent.
Occasionally, in stout subjects, it may appear difficult to
define the exact outline of the tendon, and the spot where
the knife is to be inserted. In such cases we may bring
the tendon momentarily to the surface by requesting the
patient to try to bend the knee. With these precautions,
no danger of wounding other parts exists. The external
branch of the popliteal nerve has sometimes suffered in¬
jury, probably through the section of the biceps having
been performed too near its insertion, or from the opera¬
tion having been too boldly performed. When free mo¬
bility of the joint within even a limited range exists, it is
right after the operation to apply either to the posterior
or lateral aspect of the knee a splint suitably bent or
adjusted, with the view of preventing movement of the
severed parts. If, however, the part be immovable by
ordinary handling, or by moderate pressure, the splint is
superfluous.]

No violent attempt to effect immediate reduction of
the ankylosis should be made; and it is important to
await complete cicatrisation of the punctures before the
application of extending apparatus. Neglect of this pre¬
caution may separate the agglutinated puncture, lacerate
the cellular tissue of the ham before it is perfectly cica¬
trised, and by providing a spot for the commencement of
suppuration, occasion a considerable abscess among the
structures of this important region ; whereas I have never
witnessed the slightest delay in the cicatrisation, the most
trifling blush of inflammation, or one drop of pus, where
rest of the limb has been scrupulously enjoined.

On union of the punctures, the more important portion
of the treatment, the gradual removal of the deformity,
may be commenced.

LECTURE V.

Replacement of articular surfaces in angular Imee-anhjlosis — Knee-ex¬
tending instruments—Restoration of movements in the joints—The
advantage of tenotomy — Complete immobility of anlcle ■— Deformity
of the anlcle from injury, scrofula, and rheumatism, resembling talipes
equinus, varus, and valgus—Mode of performing section of tendo-
Achillis, fyc.

In false ankylosis of the Ttnee, without displacement, the
simplest apparatus (p. 80) may suffice; but when dis¬
placement and rotation of the head of the tibia, with
eversion of the leg exist, a better adaptation of mechanical
powers to the exigencies of the case is required. The ob¬
jects to be attained are, 1, extension of the knee; 2, the
carrying forwards, and sometimes inwards, of the head
of the tibia; 3, simultaneous inversion of the leg. I have
ascertained, from repeated experience, that when atten¬
tion has been directed to remove the abnormal flexion
only, an increased displacement of the head of the tibia
sometimes resulted. Thus, supposing the relation of the
Fig. i7. tibia and femur to have been prior to

the operation, as represented in the
annexed diagram (fig. 17), the effect
of simply extending the limb will be
to change the position of the bones,
as in fig. 18, the leg having been ex¬
tended, but the displacement being
undiminished. I have in such a case
found the luxation complete, and the
extremities of the bones as move-
able as in a recent luxation from
injury,* the limb presenting to the eye of the surprised

* An “accident” from twisting by machinery, which the author once
witnessed whilst dresser at the London Hospital.

REDUCTION OF SUB-LUXATION OF KNEE.

attendant an appearance of greater deformity and weak¬
ness than before the commencement of his well-intentioned
but injudicious management. In a com¬
mon knee-extending apparatus no con¬
trivance is present to facilitate the gliding
of the bones into their proper position;
on the contrary, the pressure necessarily
exercised on the head of the femur dur¬
ing the extension forcibly urges the bones
against each other. The method of ob¬
viating this imperfection in extending
apparatus consists in employing the pel¬
vis as a fixed point, and, by making ex¬
tension from the ankle and foot, so to
draw down the entire limb as will not
only extend it, but elongate the ligaments
of the joint, and other structures exte¬
rior to it, to such an extent as will enable
the tibia to rise into its position. By
this elongation the painful pressure of
the femur and tibia against each other is
completely avoided. When the ends of
the bones are presumed to be held asun¬
der, pressure on the upper and inner sur¬
face of the condyles, and on the upper and outer surface of
the tibia and fibula, will essentially promote their reposition.
The eversion of the leg and foot is overcome by gradually
drawing the malleoli inwardly, simultaneously with the
more important process of reducing the luxation. The
utmost caution is requisite during extension to protect the
point of the knee and heel from undue pressure, as ex¬
coriations or sloughs in these situations may entirely frus¬
trate the operation.

As after tenotomy the limb will generally yield readily
to a considerable extent, a common knee-extending instru¬
ment may be applied during a week or a fortnight. This
partial restoration will prepare the limb for the more diffi-

TIME REQUIRED FOR RELIEF.

cult part of the process, for which I recommend the appa¬
ratus that is now before you (figs. 15 and 16).

On completing the extension and replacement of the
knee, the joint is usually found to be very stiff in its new
position [unless this result has been averted by well-timed
manipulations (p. 26)] ; your next object may therefore
be to restore its movements, which is often more difficult
than the previous part of the treatment. Passive move¬
ments should be diligently practised several times daily,
or as often as the tender state of the articulation will per¬
mit ; together with frictions, vapour-baths, and the appli¬
cation at intervals of the extending apparatus, its action
being reversed in order to produce flexion. It occasion¬
ally happens that, with the utmost exertion, the knee can¬
not be bent to the extent of the previous abnormal flexion.
Exercise may be permitted as soon as the limb is straight¬
ened ; but in the majority of instances, a firm mechanical
support, as an ordinary iron on the outside of the limb, with
a spring to assist the motion of the weak extensor muscles
of the knee, will be necessary for weeks or months after¬
wards, according to the severity of the case. A laced knee¬
cap may be subsequently substituted for this support.

The average length of time occupied in the straight¬
ening and reduction of the displacement of articular sur¬
faces after the operation ■, in adults, is two months; in
children the success is more rapid. The process of re¬
storing mobility, without which the individual continues
to walk lamely, is seldom completed in severe cases within
a period varying from three to six months, at the expira¬
tion of which time the patient usually walks long distances
in comparative comfort. If the articulation continue very
tender, or the deformity have existed during many years,
twelve months or more may elapse before the patient can
be considered fully restored.

Should the case have been unusually complicated, as
from adhesion of the patella, or should the permanently
abnormal position of that bone on the upper and outer

VALUE OF TENOTOMY IN KNEE-ANKYLOSIS.

part of the external condyle prevent action of the extensor
muscles, the restoration of the knee may appear to be very
imperfect. If it, however, be straight, and if the femur
be fairly in apposition with the tibia, and the joint admit
of motion in a range varying from 20° to 40°, the patient
will be able, without artificial aid, to walk long distances
with perfect ease, and will be very grateful for the change
in his condition.

No class of deformity better illustrates the advantage
of the Stromeyerian operation for the relief of deformities;
for although the relief afforded by this method, when pro¬
perly conducted in cases of club-foot, may appear to be
more complete (as not only the form but the mobility of
the ankle and the development of the muscles will be
more nearly perfect), yet the consideration of the compa¬
ratively greater importance and size of the knee-articula¬
tion, the circumstance that angular deformity of that joint
necessarily impairs the functions of the corresponding ankle,
together with the greater amount of lameness attendant on
contracted knee than on club-foot, will suffice to shew that
relief of knee-ankylosis by tenotomy is as great an addition
to the healing art as that of club-foot. White-swelling, for
example, popularly regarded with horror, is indeed divested
of its terrors, when it is considered how rarely, in the pre¬
sent day, owing to the improved mode of treating the
disease in its earlier stages, amputation is adopted; and
that, notwithstanding that this disease is peculiarly prone
to terminate in deformity, it constitutes the most favour,
able form for dividing tendons, the subsequent mechani¬
cal treatment being more easy, and the restoration of the
limb more complete, than in ankylosis from rheumatism,
or from extensive suppuration from phlegmon.

Complete immobility (true ankylosis) of the ankle is un¬
common, and need not detain us long. If the foot, although
immovable, be flexed to a right angle, so that the entire
sole be applied to the ground, locomotion may be readily
effected, and the assistance of art be unnecessary. Incon-

PARTIAL ANKYLOSIS OF ANKLE.

venience is, however, sometimes experienced from the entire
weight of the body being borne by the heel, and consequent
transmission of shocks through the necessarily extended
knee to the spinal column and its contents. This may be
obviated by recommending the patient to wear a shoe with
the heel sufficiently elevated to produce a small amount
of flexion of the knee, and thus interrupt the continuous
straight line through which the shock is communicated to
the frame.

Deformity with incomplete ankylosis of ankle .—The more
frequent form of this affection results from strumous in¬
flammation of the bones entering into the composition of
the ankle-joint. You will find that in such cases the
disease usually commenced in the lower extremity of the
fibula and adjacent parts of the astragalus and os calcis,
succeeded by suppuration and caries. The ankle-joint is
weakened by the degeneration
of the osseous and ligamentous
structures which should sup¬
port it on its external aspect,
the patient is inclined to tread
on the inner edge of the foot,
and the peronei muscles being
henceforward relaxed, gradu¬
ally contract and elevate the
outer edge of the foot. The
progress of the disease is usu¬
ally slow, several months, or
two, three, or more years,
elapsing before the ulcers
completely heal. Cicatrisa¬
tion is accompanied with the
deposit of adventitious tissue
beneath the skin in the tract
of the previous suppuration.
This abnormal tissue consti¬
tutes firm bands of adhe-

DIFFERENT FORMS.

sionsj connecting the eroded or carious extremity of the
fibula with the astragalus and pig 20

os calcis; and by the occurrence
of that contraction in its fibres
which is peculiar to newly-form¬
ed tissue, the elevation of the
outer edge of the foot is aug¬
mented. Increase of deformity
rapidly follows the disturbance
of the equilibrium of the muscles.

The peronei so completely ob¬
tain the preponderance, that a
considerable eversion of the toe
is added to the elevation of the
outer margin of the foot. The
heel is elevated by contraction of
the gastrocnemii. (See fig. 19.)

Rheumatic inflammation of
the foot may induce immobility
and a similar contraction with
deformity. But if the rheuma¬
tism do not especially affect the >=
synovial membrane; but through ;
the continuance of chronic in¬
flammation in the muscles, ten¬
dons, ligaments, and fasciae, on j
the posterior and internal aspect \
of the ankle, and particularly in Deformity of a,nMe from articular dis-
the sole, it induce so great atony ease resemblms talipes e i uinus -
in their fibres as will permit a sinking of the tarsal arch,
a kind of flat foot results. Eversion of the toes, and
stiflness of the tibio-tarsal articulation, causing the indi¬
vidual to walk on the inner margin of the foot, accompany
the deformity. Vide Flat-foot.

Deformity of the ankle from disease of the leg-bones
may likewise occur in the extended position (fig. 20), si-

DIAGNOSIS FROM OTHER FOOT-LAMENESS.

milar to talipes equinus. Here also is the model of a foot
which had been contracted for twenty years in the form
Fig. 21 . of talipes equino-va-

rus (fig. 21).

In this instance the
foot is not simply ex¬
tended through con¬
traction of the gas-
trocnemii, but the
toes are inverted from
shortening of the ad¬
ductor muscles and
of internal ligaments
of ankle, assisted by
contraction of cica¬
trices.

I have met with a
perfectly similar de¬
formity from fracture
of fibula and injury
to ankle-joint. You
will experience no
difficulty in distin¬
guishing deformity of
the ankle caused by
disease or accident

Deformity of ankle from disease of leg and tarsal bones „ . .. ,

in the form of equino-varus (elevation of heel with" in- from Similar changes
version of fore part of foot). The perpendicular line j n the f orm and posi .
a b, passing through the axis of the leg, shews the m- r

ward inclination of the anterior part of the foot, the tion of the part, Such
little toe being alone situated on the outside of that ■, •, n ■,

line. The patient, therefore, chiefly walked on the ClUD-IOOt, and pa-
hall of the little toe: c, prominent metatarsal joint of paly tic and spasmodic
great toe; A, heel; e, projecting edge of articulating ~ . . ■> .

surface of astragalus ; a, contracted abductor pollicis, deformities, Ihellis-
which had approximated the great toe and heel. tQry Q f the cas6} the

nature of the stiffness, the dependence of the muscular con¬
traction on causes primarily affecting the structures com¬
posing the articulation, will determine the diagnosis.

TREATMENT OF STIFF-ANKLE.

In each of the forms of deformity of the ankle which I
have described, the rigidity of the articulation, whether
resulting from adhesions within or without the capsular
ligament, or from the consecutive muscular contraction,
may be so considerable that scarcely any mobility of the
bones entering into the composition of the articulation may
be perceptible; thus, an opinion of the curability may de¬
pend on the detection (whilst manipulating the limb) of
slight alternate tension and relaxation in the tendons of
the contracted muscles.

The amount of lameness arising from these affections
is often very considerable, and the inconvenience and pain
experienced by the individual are usually greater than
might be believed to exist. The circumstance which, in
addition to the pain and discomfort attendant on locomotion
with a stiff ankle-joint, occasions a ready application for
relief, is the constant tendency evinced in the severer forms
to increased lameness and deformity, consequent on the
disturbance of the equilibrium of the muscles, and on the
weight of the body being transmitted to the astragalus,
whilst this bone is not situated horizontally beneath the
axis of the limb, so as properly to communicate the weight
through the tarsal arch to the ground. The portion of
integument on which the greatest pressure in walking is
exercised becomes excoriated or covered with painful corns,
and sometimes severely inflamed.

Treatment .—The general treatment applicable to anky¬
losis (p. 58) may be resorted to with equal advantage in slight
cases, in which the stiffness of ankle does not amount to
apparent immobility. But if, from the duration of the af¬
fection, the intensity of contraction, or the failure of less
active means, the case be judged irremediable without sec¬
tion of the more prominently contracted muscles, you may
perform this operation ; and it is fortunate that the treat¬
ment is liable to be attended with fewer inconveniences
and interruptions than the similar affection of the knee-

MODE OF DIVIDING TENDO-ACHILLIS,

joint. Should contraction in the extended position of the
foot exist, subcutaneous section of the tendo-Achillis will,
in most cases, sufficiently relax the articulation to permit
its restoration; if the foot be rigidly fixed in the position
of talipes equino-valgus (elevation of the heel with ever¬
sion), the peronei may require division; if in that of T.
equino-varus (elevation of the heel with inversion), the
posterior tibial tendon* and plantar fascia should be in¬
cluded in the operation. In slighter modifications of each
of these varieties, you should be satisfied with severing the
tendo-Achillis, and trust to mechanical extension for the
elongation of the remaining contracted muscles and fasciae.

[The subjects of figs. 19, 20, 21, were treated from
ten to fifteen years ago by section of tendo-Achillis only.
The author has frequently heard from the patients and
from medical friends that the restoration has been com¬
plete and permanent, no tendency to recontraction and
deformity having been manifested.

Division of tendo-Achillis is perhaps the simplest and
least painful of surgical operations, effected in a few se¬
conds, and absolutely without any effusion of blood. For
many years past the author has been accustomed to place
the patient in the prone position ; and whilst an assistant
endeavours to bend the ankle, introduces a small straight
tenotome through the integuments from behind forwards
at the side of the tendon. As soon as the point of the
instrument is judged to have reached the anterior surface
of the tendon, it is passed in front of it; the cutting edge
is then directed to the tendon, severing the tense cord by
one or two movements of the blade against it, and without
wounding the integuments, except by the puncture of
entry. The assistant should carefully relax the pressure
he may be exercising upon the foot in proportion as he
feels the part is cut through.

* The author has omitted the assertion that the flexor longus pollicis may
require division.

POSTERIOR TIBIAE, AND PERONEI.

Division of peroneus longus and brevis is similarly-
effected by placing the patient prone, or somewhat on one
side, an assistant holding the foot inwardly, so as to main¬
tain extra tension upon the parts to be severed.

In the few cases of stiff-ankle (partial ankylosis) re¬
quiring section of posterior tibial, the tendon of this muscle
is usually so prominent to the eye and touch above and
behind the internal malleolus (see p, t, fig. 20), that it is
an easy matter to sever it by inserting the point of a nar¬
row straight scalpel at the posterior edge of the tendon,
directing it forwards between the tendon and tibia, so as
to divide it without risk of injury to the posterior tibial
artery or internal saphena vein.

It is unnecessary to give particular directions for di¬
vision of plantar fascia, those given respecting operations
on other tendons being amply sufficient. However, its
division is not commonly required in partial ankle-anky¬
losis. After any of these operations, when any mobility
of the joint exists, the limb should be placed upon a splint.
But in the majority of the cases of ankle-ankylosis requir¬
ing operation, the part is so stiff that no splint is requisite.
Gentle extension may be commenced after the lapse of
two or three days.]

I shall describe the apparatus applicable to these cases
in a future lecture on some other deformities of the ankle.
(See Club-foot.)

LECTURE VI.

Contracted toes from rheumatism and improper shoes—Deformities of
the shoulder, elbow, wrist, and finger-joints — Treatment — Deformi¬
ties from causes indirectly affecting the articulations — Contractures —
Distortion from simple repose of a member; from superficial or deep
abscess; from laceration, sloughing, gun-shot wounds among the fleshy
parts; from burns, cicatrices, ulcers, and cutaneous disease; from
hypertrophy and induration of fascia.

Rheumatic inflammation of the entire foot is occasionally
succeeded by considerable rigidity of tbe phalangeo-meta-
tarsal articulations, with thickening of the tissues surround¬
ing them, and much deformity—partial ankylosis. The
metatarsal articulation of the great toe is more apt to suffer
than the remainder, and more particularly from gouty in¬
flammation. Occasionally the affection of these minor
articulations co-exists with contracted ankle-joint, or it
may be accompanied with considerable contraction of the
muscular and fibrous tissues of
the sole, in which case the re¬
traction of the flexor tendons
causes rigid flexion of the whole
of the phalanges, except the first
phalanx of each toe, which re¬
mains extended, in consequence,
I believe, of the resistance op¬
posed to the flexion of the whole
of the phalanges by the extensor
tendons. On examination you

Contracted toes from rheumatism, re- will find the flexor and extensor

lieved * seetion offlexor teadons * tendons equally contracted; but

* The patient was a military officer, who in consequence of the pain and
lameness experienced during locomotion had been invalided. He was restored
to perfect activity.

Fig. 22.

CONTRACTED TOES — TREATMENT.

as the contraction of the extensors is consecutive, the
relief of the contraction of the flexors will, unless the
case be of long standing, enable the toes to resume their
proper position.

Considerable inconvenience in walking is experienced
from this contraction of the toes; less, indeed, from the
simple alteration of their position, than from the pain pro¬
duced by the weight of the body being continually thrown
in an improper manner on the metatarso-phalangeal articu¬
lations. In the natural relation of these parts the inferior
round extremity of each metatarsal bone is received into
the concave articular surface of the corresponding phalanx,
and the metatarsal bone and phalanx each obtains its share
of the weight imposed on the. anterior extremity of the
foot in locomotion ; hut when the first phalanx is extended
in the manner above described, the inferior part of the ar¬
ticulation, and the round head of the metatarsal bone, are
more exposed to pressure, and the ligaments are incessantly
stretched and inflamed, causing continued suffering in
walking.

Friction and manipulation should be employed in the
treatment of these cases when they are slight ; but as ar¬
ticulations affected with rheumatism usually remain tender
for a considerable time after cessation of the inflammatory
process, the patient will scarcely desire or permit any at¬
tempt to remove the resulting deformity until considerable
inconvenience has been experienced. These cases com¬
monly exist during several years before relief is sought, so
that you will rarely be enabled to effect their restoration
without section of the flexor, and sometimes of the ex¬
tensor tendon. When the complication of contraction in
the sole exists, division of the plantar fascia may be essen¬
tial. After the operation, and cicatrisation of the punctures,
each toe should be secured by adhesive plaster, or by ban¬
dage, to appropriate splints, by which its perfect straight¬
ening may be accomplished.

DEFORMED TOES FROM IMPROPER SHOES.

A contracted and deformed state of the metatarsal joint
of the great toe, and of the articulation of the first phalanx
with the second phalanx of the second toe, produced by
wearing improper shoes, is very common, and requires to
be treated on principles similar to those which are appli¬
cable to contraction from rheumatism.

Figs. 23 and 24.

formed foot.

[In cases of deformity of metatarsal joint of great toe,
as represented b, fig. 23, much pain is experienced on
locomotion from a state of constant chronic inflammation
of the articulation, the principal seat of the suffering being
the internal surface of the joint. It would appear that
the internal lateral ligament of the joint especially suffers,
in consequence of the tension maintained upon it through
the habitual thrusting outwardly of the extremity of the
toe. In time the extensor tendon of great toe, the altered
direction of which is seen in relief, fig. 23, tends to increase
the deformity. Removal of the pain experienced at b is
obtained by lightly bandaging a thin splint of wood or
whalebone along the inner margin of the foot and great
toe, avoiding pressure against b by suitable padding.

By means of this splint the great toe is gradually

DEFORMED TOES FROM FLAT-FOOT.

brought into a line with the inner margin of the foot, the
lateral ligaments are no longer stretched, and unless an
improper shoe he again worn, the parts soon recover a
healthy state. Remedies calculated to relieve chronic
inflammation of the joint may occasionally be required.
Some severe cases of this deformity depend upon the si¬
multaneous operation of another cause—relaxation of the
tarsal arch, as in flat-foot. The natural direction of the
toes is slightly outwards (fig. 24); consequently, when an
undue strain is exercised upon the muscles of the toes,
through the sinking of the arch, an excessive eversion of
phalanges results. The sinking of the arch affects prin¬
cipally or exclusively the internal part of the sole, and
consequently tbe great toe mainly suffers.* Other forms
of contracted toe of similar nature occur; but as their
treatment will be intelligible from what has been here
stated, it is unnecessary to dwell upon the subject.]

I have so little to say concerning contractions and dis¬
tortions of the upper extremity from injury and disease of
the articulations, that I shall be able speedily to dismiss
the subject. A stiff immovable shoulder, from rheumatic
inflammation of the capsular tissues and articular surfaces,
affords a not uncommon example of incomplete ankylosis.
The obstacles to the recovery of the articulation thus af¬
fected are, first, the tender state of the articulation remaining
after cessation of the acute stage of the rheumatic inflam¬
mation, probably from persistence of chronic inflammation;
secondly, alteration of the quality of the synovial secretion,
with thickening of the capsular structures, and perhaps oc¬
casionally membranous adhesions, the whole of the symp¬
toms being aggravated by the long-continued cessation of
the use of the part, and consecutive muscular contraction.
The symmetry of the part is destroyed, principally from
wasting of the deltoid. You may sometimes be enabled

' * Vide paper on pathology of this deformity, read at London Medical
Society, Nov. 9, 1850, by Mr. Conlson.

ANKYLOSIS OF ELBOW-JOINT.

successfully to treat such instances of imminent complete
ankylosis, even where other articulations may have been
previously affected with true ankylosis,—first, by the admi¬
nistration of iodide of potassium or quinine, and some¬
times by colchicum and alkaline remedies, according to the
condition of the stomach and kidneys, and of the general
health ; secondly, by counter-irritation, frictions, manipu¬
lations, and passive movements of the joint.

Another deformity, the consideration of which properly
belongs to this place, is the long-unreduced dislocation of
the shoulder, occurring from accident. These cases, for¬
merly considered irremediable, illustrate the advantages
resulting from division of tendons, as a preliminary to
mechanical efforts to reduce the displaced bone. Dieffen-
bach has related two instances, the one in which reduction,
after two years’ luxation, was readily accomplished, with
perfect recovery of the function of the joint, through sec¬
tion of the tendons of the pectoralis major, latissimus dorsi,
and teres major and minor muscles. In the other, luxation
having existed “ many years,” the same tendons, as well as
the articular capsule, were divided, with only indifferent
success.

[Many cases are scattered amongst the periodicals of
the last few years illustrative of the utility of tenotomy in
reduction of fractures and dislocations.*]

Stiff elbow-joint occurs more commonly than any similar
affection in other parts of the upper extremity. In addi¬
tion to ankylosis from traumatic causes, the mobility of
the elbow is often annihilated by rheumatism, by abscesses
consequent on fevers, and, even more frequently, by stru¬
mous disease of the articular extremities. When it results
from traumatic or rheumatic inflammation, the immobility
may be considerable, depending, nevertheless, on thicken¬
ing of the ligaments and tissues exterior to the joint, and

* Tamplin, London Medical Gazette, July 1850. Campbell de Morgan,
Lublin Medical Press, Dec. 1849.

TREATMENT. TENOTOMY AT ELBOW.

slight, if any, adhesions within. Consequently, entire
mobility may he regained hy a judicious use of the means
hitherto enumerated.

[In the elbow, owing to its complicated structure, per¬
haps more than in any other articulation, it is important
not to neglect the use of manipulations and occasional
instrumental bending of the part during the employment
of extension (p. 27). A case of incomplete ankylosis of
elbow in the flexed position, which, after straightening,
could not again be bent, fell under the observation of Mr.
Lonsdale. Malgaigne, in his recent classical work on
fractures, states that immobility of a joint in the extended
position only is followed hy ankylosis, through the muscles
upon all sides of the member powerfully pressing the articular
surfaces against each other, and thus exciting a morbid
action in them, favourable to complete ankylosis.]

Caries of one or more of the articular extremities often
succeeds struma. The mobility may then he free within
a given range, probably to the extent of a third or a half
of the natural movement; but a sudden check to further
flexion or extension, according to the direction of the re¬
sistance, will be experienced on examination. The per¬
formance of perfect extension is more often interfered with
than flexion. In these cases restoration can only be ef¬
fected by persevering gradual application of mechanical
power and the auxiliary remedies. Various instruments,
the majority consisting of different applications of the
common male and female -screw [or ratchet-screw], have
been recommended for this purpose. In slight cases, a
common straight splint, bound with moderate tightness,
will suffice. Tenotomy may be advantageously resorted
to in cases that have long existed. The parts which 3 pm
may have to divide are the tendon of the biceps, and
sometimes the mass of muscular fibres arising from the
external condyle of the humerus.

[These are cases in which anaesthetics for the purpose

CONTRACTED HAND FROM RHEUMATISM.

:,f: of aiding an accurate diagnosis are available. See p. 43.

Too sanguine a prognosis should be avoided.]

3 ^.* The articulation of the wrist is peculiarly liable to be¬
come contracted from accident or disease. Often the
; f amount of induration beneath the integuments and fascia
of the part is so considerable as to occasion doubts of the
existence of complete osseous adhesion of the bones. Oc¬
casionally, when voluntary movements by the muscles of
the joints are entirely suspended, passive movements of the
part, as of other articulations which are similarly affected,
are accompanied with a distinct crepitating sensation, per-'
ceptible to the ear and touch. A roughness of the articu¬
lating surfaces, depending either on diminution or cessation
of the secretion of the synovial membrane, on ulceration,
or attrition of cartilages and probably most frequently,
in gouty cases, on the crystallisation of the urates of soda,
or ammonia and phosphate of lime (tophaceous matter),
secreted within and around the articulation. The articu¬
lations of the fingers are equally liable to ankylosis from
the causes here mentioned, and the deformity produced in
mg. 25. them by gout is very considerable. Oc-

casionally the cretaceous matter is so

J f f [i- V' abundant that the superincumbent skin .

yields to the pressure exercised from
within outwardly, and is slowly removed
(tf \f ‘ i by absorption, rarely with suppuration.

I fpl By these means the tophaceous matter,

% J f constituting “ chalk-stones,” is thrown

f' r y [In many cases of incomplete anky¬

losis after rheumatism, the articulations
i of the phalanges have undergone so great

Tot CrZ a change, in consequence of erosion of
veiihier. a common de- articular surfaces, as to render restoration

formity, often combined . *

with much eversion of impossible. In others the contraction
fingers. and deformity have resulted from extra-

TREATMENT.

101

articular disease, rheumatic affection of ligaments, muscles,
and tendons; perhaps, sometimes, of the muscles and their
tendons only.*

The study of fig. 25 throws light on the manner in
which contraction of muscular structures produces defor¬
mity. In the majority of deformities—as, for example,
in those produced by spasm and paralysis—volition is so
greatly impaired, that one set of muscles obtains a decided
preponderance, and the part is contracted in the direction
of flexion or extension only, as the case may he.

In this particular rheumatic contraction, however, we
find that both sets of muscles, flexors and extensors, volition
balancing them, are shortened; the result of which is, that
the total length of the member (the'hand) is diminished,
one row of phalanges (the first) being flexed, the next (the
second) being extended, and the terminal row again flexed.
Compare with this figure the hand represented page 109,
in which the whole of the phalanges are flexed.]

As regards the treatment of stiff wrist, I may observe
to you, that if the deformity have arisen from accident, or
phlegmonous inflammation, or if the cause have been struma,
the case being complicated by the cicatrices of fistulas in
different situations among the carpal hones, and complete
immobility exist, it may he considered incurable. But in
cases of incipient ankylosis from “ rheumatic gout,” all
appearance of inflammation having subsided, you may be
enabled to restore the functions of the part. j' Frictions,
manipulations, baths, the internal administration of iodide

* A deformity induced by disease of muscles and tendons only should come
under the head of Contracture, rather than under that of incomplete ankylo¬
sis, illustrating the common observation in natural history, that objects in
nature are not capable of that absolute separation into classes which science,
for convenience, demands.

f Extended observation shews that this apparently incipient ankylosis is
more often a state of contracture, no alteration of the articulation itself existing.
The author has restored numerous hands and fingers contracted by rheuma¬
tism simply by manipulations.

102

ANKYLOSIS OF WRIST.

of potassium, and attention to the functions of the liver
and kidneys, constitute the remedies you should employ.

Ordinary stiff wrist-joint, occurring from common in¬
flammation, whether preceded by accident or not, usually
yields to the general remedies that are applicable to all
cases of false ankylosis. Sometimes the flexor tendons re¬
main tense and contracted, and insuperably oppose every
attempt at mechanical extension. Tenotomy should in
such cases be resorted to, and the resistance offered by
the palmaris longus, the flexor carpi radialis, the tendons
of the flexor sublimis, and even the flexor carpi ulnaris,
may thus be removed. The section of as many of these
tendons as may be necessary should not be effected by a
common puncture; *each should be divided at a different
distance from the articulation, or on successive occasions,
so as to obviate the chance of their becoming agglutinated
in a common subcutaneous cicatrix, and consequent im¬
pairment of function. I shall more particularly allude to
these operations when describing to you the deformities
from paralysis and spasm.

The apparatus you may employ to effect straightening
of the wrist may consist of a series of metallic splints,
adapted to the size and form of the hand and arm, and
bent at different degrees opposite the wrist. By com¬
mencing with the application of one that is bent to nearly
the same extent as the affected joint, the pressure is readily
borne. [Straight splints connected by an adjusting ratchet-
screw may also be employed.] Similar deformity of the
fingers, generally, yields to [manipulations and] mecha¬
nical means, unless the flexor tendons have sloughed, or
become adherent to their sheaths, from the previous in¬
flammation, Occasionally you may find section of the
flexor tendon [in the palm] requisite. A finger is more
unserviceable and deformed when fixed in a straight posi¬
tion ; this is usually preceded by destruction of the flexor
tendon: the extensor then draws the finger unnaturally

CONTRACTURE, ITS NATURE.

103

backward. Division of the extensor would be inoperative
when the three phalanges are united into one bone. It
is probable that a finger which is ankylosed in this manner
may be transformed into a useful member by dividing one
or more of the phalanges, and causing reunion to take
place, in a curved position.*

I proceed to consider a very important class of defor¬
mities, namely, those which arise from causes indirectly
affecting the articulations , to which I assign the term of

Contractures.

The class of deformities the description of which I
have just concluded, is produced by causes which operate
directly on the joints, viz. injuries and inflammation in its
various forms. If you have well understood my remarks
thereon, you will remember that the serious character
of those deformities depends on organic changes in the
articular structures. The study of contractures will be
facilitated by considering that the important articular struc¬
tures are not necessarily involved in any morbid process.
The deformities which I shall include in the term contrac¬
ture are probably more numerous than those which are
comprehended under any other subdivision, and therefore
I shall detain you with some remarks on contracture in
general before describing the individual distortions of this
nature. This is the more necessary, as I am aware of no
adequate source of information on this subject to which I
can refer you. -

Contracture is the state of imperfect mobility, rigidity
or immobility of an articulation, produced and maintained
by causes which operate at a distance from the articulation.
It is a passive state, the effect of contraction, and not the
contraction itself, with which it is often confounded. The

* Dr. Gordon Beck, of New York, has since performed a similar opera¬
tion. A knee-joint completely ankylosed at a right angle was restored to
nearly a straight position by removal of wedge-shaped portions of femur and
tibia .—Medical Gazette, May 1846.

104

CAUSES OF CONTRACTURE.

term has "been applied by French writers to the muscular
retraction of the limbs of children, produced by “ spinal
irritationbut it requires, in my opinion, a more exten¬
sive application. In the lectures on deformities from an¬
kylosis, I have shewn you that in those affections the passive
organs of motion are the parts primarily diseased; whereas
in contracture the articulation becomes only secondarily
involved, the parts primarily implicated being the active
organs of motion, the muscles and tendons, or the skin
and aponeuroses. In both affections the abnormal condi¬
tion of one set of structures ultimately involves the other,
deformity from disease of joint
(ankylosis) being combined with
muscular contraction, and this
condition of muscles, when pri¬
mary,inducing ultimately rigid¬
ity and shortening of ligaments,
but never true ankylosis,*
Contracture may, therefore,
be produced by various causes
which disturb the equilibrium
of antagonist muscles; namely,
simple rest of the part [habitual
use of in certain occupations,
retention in one position], as
in the distorted limbs of super¬
stitious devotees in India, ex¬
tensive erysipelatous inflam¬
mation, abscess beneath the
superficial fascia or burrowing
among the deeply-seated mus¬
cles, loss of substance in the muscles and tendons from

* Malgaigne, in opposition to Cloquet and Tessier, adopts the opinion
advocated by the author, that repose or immobility of a joint is not alone capa¬
ble of producing ankylosis, but that inflammation, or one of its results, is ne¬
cessary for the purpose; and quotes a case related by Cruveilhier, in which,
after 60 years’ immobility of the jaw, no ankylosis existed. (Treatise on
Ankylosis, by the Author, 1843.)

Fig. 26.

incomplete knee-ankylosis from stru¬
mous disease, with much suk-luxation,
and numerous indented cicatrices re¬
sulting from suppuration, restored to
straight and serviceable position by
section of ham-strings. Fig. 12 should
have appeared on this page, as it repre¬
sents a 'knee-contracture from phlegmo¬
nous erysipelas, in which the articula¬
tion was only indirectly affected.]

CAUSES OF CONTRACTURE.

105

sloughing, gangrene, laceration by machinery, gunshot
wounds, and burns, the cicatrix of which contracts the ad¬
jacent articulation. The long continuance of a sore state
of the cutaneous surface, which favours repose of the limb,
or its voluntary retention in a particular position, as. from
inveterate psoriasis, or eczema, or from an obstinate ulcer,
may induce contracture of the neighbouring joint.

An interesting case of contracture from a superficial
ulcer of many years’ duration, was recently shewn to me
by my colleague at the London Hospital, Mr, Curling.
Contractures from a sore state of the cutaneous surface
result, in my opinion, from the voluntary retention of a
limb in a position calculated to relieve the soreness. It
is at the same time not improbable that in some instances
an incident and reflex action of the cutaneous nerves (via
the spinal cord) on the motor filaments of the subjacent
muscles may be a cause of their contraction; at all events,
the fact of the occurrence of morbid muscular contraction
from irritation of the cutaneous surface may, as Stromeyer
remarks, lead with more confidence to the therapeutic
employment of vesicatories and rubefacient applications, as
a means of restoring tone to debili¬
tated muscles.

Hypertrophy and induration of
fascia, whether obviously preceded
by inflammation or not, are often
accompanied by shortening in its
fibres and contracture of the nearest
articulation, as in contracted fingers
and toes, from disease of the palmar
and plantar fasciae. But the most
frequent causes of contracture are
spastic contraction and paralysis of
muscles, both of them being causes
which -destroy the equilibrium [main- Contracted finger from disease
_ _? . , of palmar fascia.

tamed by the will] of opposing sets
of muscles.

Fig. 27.

106

LECTURE VII.

Spasmodic contractures — Distortions from functional or organic disease
of brain and spinal cord — Spastic contraction of a single muscle, of
a set of associated muscles, of analogous muscles in upper and lower
extremities — Effects of spastic contracture — Disturbance of sym¬
metry of frame—[Origin of rigidity of limbs in new-born infants —
Asphyxia neonatorum]—Paralytic contractures—Points of resem¬
blance with spastic contractures—Apparent anomalies—Talipes cal-
caneo-valgus.

The simplest case of contracture from spastic contrac¬
tion is that of the slightest form of talipes equinus,* or
Fig. 28 . T. equino-varus, gradually induced

^ by derangement of the mucous mem-

brane of the alimentary canal, whe-
W’ ther it arise from the irritation of

worms and improper food, or consist
^ of chronic inflammation. The series

~~ —= ~ of morbid phenomena is produced by

Talipes equinus slight. means of the chain of filaments on

which the reflex functions of the nervous system depend.
Contraction of the sterno-mastoid muscle, producing wry¬
neck, may have a similar origin. [Frequently a spastic
contraction of a muscle and consequent deformity of the
member are gradually produced by imperfect nutrition and
impairment of the general tone of the individual. The de¬
terioration of health is principally evinced by derangement
of the nervous system, of which the spastic contracture is
the outward manifestation. Such cases are analogous to
chorea as respects predisposing and proximate causes, espe¬
cially in the earlier stages of that disease, when, as some¬
times happens, the functions of a single muscle, or the
muscles of a single articulation, may be impaired. The

* Talipes equinus—elevation of heel, T. equino-varus=elevation of heel
with inversion of toes, as in fig. 21.

SPASTIC WRY-NECK.

107

spastic contraction of muscle, which produces contracture,
differs, however, by its permanency, from the involuntary
hut transient muscular contraction of chorea.]

Other cases occur in which the deformity takes place

Fig. 29.

Wry •neck from spastic contraction of sterno-mastoid muscle .

more rapidly, depending upon sudden derangement of an
internal organ, involving a peripheral part of the nervous
system (as in a respiratory or chylopoietic organ), or on
some functional or organic disease of its central parts—the
brain, cord, or investing membranes—the spastic affection
being sudden, and the contracture of the articulation com¬
plete.

The effects of the derangement of the brain or cord
may be limited to the functions of a single muscle, as the
gastrocnemius in talipes equinus, or the sterno-mastoideus
in the simplest case of wry-neck; or a larger number of
nervous filaments and more numerous muscles may be
fected, as in talipes varus (figs. 30, 46), in which the ad¬
ductors of the foot are attacked conjointly with the gastro-
cnemii; or, as in severe wry-neck, in which the scaleni,
trapezius, and probably other muscles, are implicated.

Spastic iton-congenilal Talipes varus. That placed uppermost is a front view : the one on
the left is a posterior view; and that on the right, the foot seen from behind. The
letter a, in each drawing, indicates the tendon of the anterior tibial muscle; b, in the
drawing on the right, shews the situation of the external malleolus; c, in the upper¬
most drawing, a process corresponding with the anterior extremity of the os calcis; d,
in each, the heel raised from the ground; e, the posterior extremity of the fifth meta¬
tarsal bone; /, the tendo-Achillis, passing in a curved direction to the posterior tuber¬
osity of the os calcis, apparently deviating inwardly,* but actually having its insertion
nearer to the external malleolus than in a sound limb; g, in the left drawing, the out¬
line of the tendon of the posterior tibial muscle.

* The heel and tendo-Achillis are generally described as being twisted
inwardly in Talipes varus; it will nevertheless be found, that although the
tendo-Achillis passes in a curve towards its insertion, the convexity of the
curve being directed to the fibula, its course, and the posterior extremity of
the heel, are actually nearer to the external malleolus than in the natural
relation of these parts. The curve formed by the tendon is probably caused
by the rotation of the foot on its antero-posterior axis ; the approximation of
the posterior extremity of the heel to the external malleolus results from the
navicular bone being drawn by the anterior tibial muscle towards the internal
malleolus, and the consequent adduction of the foot. The adduction being

CONTRACTION OF ASSOCIATED MUSCLES.

109

may be deranged. A corresponding arm and leg may be¬
come contracted, inwbicb case si.

it will be found that the mus¬
cles of the upper extremity
analogous in situation and use
to those in the leg will be
seized. Thus, if the gastro-
cnemii be spasmodically con¬
tracted, the flexor muscles of
the wrist will be the parts in¬
volved in the upper extremity;
if the gastrocnemii and ad¬
ductors of the foot be affect-,
ed, the flexors and pronators
of the wrist will be conjointly
disturbed. When both lower
extremities suffer, both arms
not unfrequently participate
in the disturbance.

On simultaneous seizure
of the four extremities, a greater tendency to spontaneous
restoration, or a greater susceptibility to the operation
of remedies, is evinced on one side of the frame than on
the other, usually on the right side; so.that the patient,
when presented to your notice for relief of the resulting
deformity, has partially or completely recovered the use
of one arm or leg.

Analogous muscles in the upper and lower extremities,
and those most frequently associated in their physiological
actions, are liable simultaneously to participate in spasmo¬
dic affections, and to become simultaneously contracted,
inducing particular contractures. This is so invariable as
to amount to a pathological law. In the natural actions of

Contracture of hand from spastic shorten¬
ing of flexors and pronators. Biceps cu¬
bits also contracted.

effected by a horizontal rotation of the astragalus, the posterior extremity of
the tarsus, formed by the os calcis, is thrown outwardly, in proportion as the
front part of the tarsus and foot are drawn inwardly.

110

SIMULTANEOUS CONTRACTURES.

the upper extremity the flexor muscles are more commonly
associated with the pronators
(of which, in the leg, the ad¬
ductors are analogues), the
extensors of the arm with the
supinators (in the leg the ab¬
ductors) ; and when the upper
extremity is affected with spas¬
tic contraction, the flexors will
he observed to suffer con¬
jointly with the pronators (in
the leg the flexors* with the
adductors), the extensors of
the arm concurrently with the
supinators (in the leg the ex¬
tensors with abductors).

This law applies not simply
to the abnormal actions of
the muscles of a single limb;
for when the upper and
lower extremities are simul-

Contracture of knee and foot from spastic taneOUsly affected in the Same

SSSSSS5 individual with spastic con-
adductors (anterior and posterior tibiat traction, an exact correspon¬
dence occurs, the flexors and
adductors of the leg suffer together with the flexors and
pronators of the arm, and never (?) conjointly with the ex-
tesnors and supinators. When the extensors and supinators

* The lecturer here explained that he agrees with Rudolphi, Walther,
Palletta, and other physiologists, in applying the term flexors to the gastro-
cnemii and other posterior muscles of the leg. He stated that they are called
extensors of the ankle-joint by some anatomists and surgeons, because they
straighten the foot by elevating the heel; but from the facts narrated in this
lecture, it is apparent that they correspond pathologically with the flexors of
the fore-arm and fingers. As regards anatomical position they are unquestiona¬
bly flexors. As an additional proof that they should be regarded as flexors, he
remarked the circumstance, that in the quadrumana the hind-feet are, by means
of these muscles, used for grasping as readily as the fore-feet.

CONTRACTURES GRADUAL OR SUDDEN.

Ill

of the arm are affected, the extensors and abductors of the
lower extremity participate in the disorder. The flexors
and adductors are more obnoxious to spasm than the ex¬
tensors and abductors.*

A more considerable derangement of the functions of
the spinal cord may occasion tonic contraction of a larger
number of muscles; the flexors of one or both knees (fig. 32)
may be affected, or the biceps flexor cubiti (fig. 31), in¬
ducing contracture of the knees or elbows, contracture of
the foot always accompanying the contracture of the corre¬
sponding knee. When the spasmodic affection is gradual ,
you will find that the muscles most distant from the nervous
centres are first affected; whence it may be inferred that a
smaller degree of disturbance in the central organ, whether
originating there or excited by disease in peripheral parts of
the system (reflex), may suffice to produce spastic contrac¬
tion of the muscles of one articulation, as the ankle or wrist;
and that on increase of derangement in the central organ,
the muscles of other joints, as the knee and elbow, the hip
and shoulder, become successively involved, the progression
being from the articulations most distant to those nearest
the trunk. Contraction of the flexor tendons of one or more
fingers is sometimes the first symptom of spastic contrac¬
ture in the arm ; and contraction of the flexor longus pol-
licis pedis, and of the smaller muscles of the sole, often
precedes spastic rigidity of gastroenemii, and other muscles
of the leg, in this form of non-congenital talipes. You
will remark the coincidence in this respect between the
progress of spasm and paralysis, when gradual.

A sudden attack of spasmodic contraction may, in pro¬
portion to its severity, attack the hand or foot, the knee
and elbow, the hip or shoulder, singly or all together. In
the thigh the adductor and flexor muscles, and in the
shoulder the latissimus dorsi, the teres major and minor,

* The author has here omitted an hypothesis to explain the reason of the
association of certain muscles.

112

APPARENT SPINAL DEFORMITY.

and the pectoralis major, are concurrently affected with
the pronators, adductors, and flexors of the wrist and foot.
The muscles of the head and trunk, of the eye, the organs
of speech and deglutition, are
sometimes involved in the disturb¬
ance, inducing squinting, stam¬
mering, or mis-enunciation, ri-
sus sardonicus, blepharo-spasmus,
[spasmodic dysphagia}, wry-neck
or opisthotonos, from tonic con¬
traction of the posterior muscles
of the head and those of the cer¬
vical and dorsal portions of the
spinal column. I have witnessed
seizure of platysma myoides and
the muscles inserted into the ra¬
mus of the jaw, and consequent
deformity of the face from de¬
pression of the affected side of
the maxilla. [In such a case the
ramus of the inferior maxilla may
appear rudimentary, and much
approximated to os hyoides.]

The muscles affected with spas¬
tic contraction may he in part or
wholly removed from,the influ¬
ence of volition ; their develop¬
ment is proportionally interrupt¬
ed, and a cessation of growth, or
’ r “lrr;322"“ even atrophy, results. Occasion-
ally hypertrophy precedes the

* The apparent spinal deformity is produced by shortening of left leg,
and disappears on interposing a book of suitable thickness between the foot
and the ground. The outward curvature of right leg is caused by a spon¬
taneous yielding to accommodate itself to the opposite shortened member.
The deformity of the right ankle is caused by the oblique direction in which
the weight of the body is thrown upon it in consequence of the curved leg.

UNIVERSAL TETANUS-LIKE CONTRACTURE.

113

atrophy, as already mentioned. Other structures, as the
bones, suffer in proportion, and the nutrition of the
entire organ is imperfect. If both sides of the body be
interested, the size of the affected parts will commonly
be found smaller than those of healthy individuals; and
if one side of the body only be affected, the normal de¬
velopment of the one side compared with the atrophy of
the other occasions a remarkable want of. symmetry. This
is often perceptible in the whole of one side of the frame ;
one half of the head, neck, chest, abdomen, pelvis, and
extremities, even when contracture exists in the limbs
only, being smaller than the opposite. It is incomparably
greater than that occasional want of symmetry observed
by anatomists and sculptors, which is not incompatible
with integrity of function.

The contractures of which I have hitherto spoken are
referrible to spastic contraction of one or more associated
sets of muscles, which is the common form of the disease ;
but you may meet with rare cases, in which the whole of
the muscles of the extremities, flexors and extensors, adduc¬
tors and abductors, &c., appear conjointly
spastically affected, the entire muscular
system being permanently affected with
tetanic stiffness, flexion preponderating
in the extremities, probably through the
powers of the flexors and adductors ex¬
ceeding that of their antagonists. Some¬
times flexion predominates in the trunk;
at other times extension, in which case
the anatomist is reminded of the fixed
retracted state of the head observed in
hemicephaloid foetuses. General spastic contraction

T ... . . of the lower extremities.

In some cases the physician is strongly
reminded of chorea, by the jerking irregular manner in
which the individual endeavours to use the limbs.

[Every form of contracture arising from spasm, which

114 CONTRACTURE FROM PREMATURE BIRTH.

I have described, may present itself either as a congenital
affection, or as the result of disease during infancy. It is
often difficult, and sometimes impossible, to discriminate
whether the case be congenital or acquired. A common
accompaniment of [congenital or acquired] contracture in
a large proportion of the voluntary muscular system, as
of two or more extremities, and particularly when at the
same time the muscles of the face and throat are involved,
is an impairment of the intellectual powers. This may
be slight, and evinced simply by excessive unsteadiness in
application to intellectual pursuits, great irritability of tem¬
per ; or more severe, causing ungovernable temper, uncon¬
trollable tendency to destroy objects, cunning, hebetude,
and weakness of every intellectual faculty, even complete
idiotcy. In some instances, however, the weakness of in¬
tellect has appeared to result less from permanent injury
to the brain than from the want of sufficient training and
education after its recovery from the severe physical shock
it had received. Epilepsy is an occasional complication.

In many instances the spasmodic affection is produced
at the moment of birth, or within a few hours or days of
that event. In the majority of the cases of universal con¬
tracture of the upper and lower extremities which have
fallen under my observation, the subjects were born at the
seventh month, or prior to the end of the eighth month of
utero-gestation. In two cases the birth occurred at the full
period of gestation, but owing to the difficulty and slow¬
ness of parturition the individuals were born in a state of
asphyxia (asphyxia neonatorum), resuscitation having been
obtained at the expiration of two and four hours, through
the persevering efforts of the accoucheurs. The fact of the
greater liability to universal spasmodic contraction of in¬
fants prematurely born is susceptible of two explanations.
I have ascertained that the premature labours in question
were rarely induced by mechanical injury or sudden appli¬
cation of other causes, such as excessive exertion or a vio-

CONTRACTURE WITH FEEBLE INTELLECT.

115

lent emotion, but were consequent on derangement of the
health of the parent of some duration. One explanation,
therefore, suggests itself, that the deteriorated health of
the parent had directly impaired the nutrition of the foetus,
and both directly and indirectly the healthy development
of the nervous system of the foetus, creating a suscepti¬
bility to disease.*

* Succinct report of a moderately severe lion-congenital case of spastic
rigidity, for which the author is indebted to Mr. Hollis of Brighton.

April 1844. A healthy, spare, wiry, fair hoy, set. four years, unable to walk unas¬
sisted; toes inverted, heels elevated during locomotion; spastic contraction of gastro-
cnemii, flexors of knees, adductors of thighs; knees separable eight inches only; volition
still imperfect in hands, pronations and flexion preponderating; apt to drop things; trem¬
bles ; when pleased, extends his limbs like an infant during excitement; when placed upon
a chair without arms, or sofa, is in constant fear of falling; some difficulty of speech;
much strabismus formerly, slight only at present. The whole attributed to “ heavy fit of
illness when cutting first tooth.”—April 24th. The Achilles tendons were divided: im¬
mediately after operation great re-action of anterior muscles of ankle observed; splints
on front of legs and feet applied to prevent bending: difficulty in keeping toes down
experienced. — May 10th. Continued apprehension of imperfect union. — June 13th.
Both tendons re-united; intermediate substance in right rather long; during the last
three weeks has worn double upright'irons; the knees maintained in extension during
night and day; the limbs on removal of irons freely flexible and extensible; walks
slowly when supported as well without as with irons; knees do not bend under him ;
knees have been separated by manipulations twelve inches; tendency to Valgus noticed.
—July’loth. To substitute for the long irons short upright'ones to tibia, as in treatment of
Valgus.—February 16th, 1845. Has run alone three months, but is unable to walk
slowly; he can stand quite upright unsupported.

The following is a still less severe case, attributed to an accident and sub¬
sequent illness at age of eighteen months, though probably dependent on
partial asphyxia at birth.

April 1844. A stout girl, set. eleven, dark eyes, fair skin, red hair, affected with spas¬
tic contraction of both gastrocnemii, especially of left; slight contraction of adductors of
thighs and flexors of knees ; volition in hands and arms imperfect; speech affected; irri-

116

CONTRACTURE FROM ASPHYXIA AT BIRTH.

The second explanation that I may offer you, and one
especially applicable to those cases of contracture concern¬
ing which doubt exists whether the spasmodic affection
originated prior or subsequently to birth, is based upon the

tellectual development, from Asphyxia neonatorum, with the particulars of
which I was furnished by the parent, a surgeon in Oxfordshire.

“The male child ofyoung and healthy parents, in consequence of protracted labour (it
being the first child), was born asphyxiated, and continued so for above half an hour.
The pressure, not instrumental, over the occiput, was to such an extent as to cause con¬
gestion and ultimately sloughing over the occipital protuberance. For several days the
child was very feeble, and unable to cry aloud; during the first two days he had several
convulsions, and did not appear likely to survive. However, after the bowels had been
well cleared by an enema, he rallied, and was pretty well, although small in size. The
only thing remarkable at this time was an awkwardness in taking the breast, so that
during the first fortnight he was obliged to be fed from a bottle. At the age of two
months he began to increase in size, and up to end of first year was remarkable for
robustness. When nursing him, it was noticed that he did not retain his seat, but slipped
off the hand or knee of the nurse. The period of dentition passed over without any dis¬
agreeable symptoms. His temper was always good. He appeared rather backward in the
use of the legs, but this was attributed to his great weight.

“ At two years of age the attention of the parents was drawn to his inability to walk or
creep on the floor, as also to his backwardness in the use of the tongue and right hand.
He was now put under the influence of electro-magnetism three times a week, of suffi¬
cient strength to be disagreeable to an adult; and during the summer was dipped in cold
water every morning. He was once during this year subjected to a course of calomel for
a period of three weeks, which induced jaundice, and made him much thinner. -His
bowels after this were continually costive, but he took very little medicine. He occasion¬
ally awoke in the night apparently frightened, and was a considerable time getting quiet

“ Soon after his third r birth-dav he could sav ‘ nana.’ imitate the cow. and knew several

his knees

STATISTICS OF GENERAL SPASTIC RIGIDITY. 117

proposition, that an infant prematurely horn is, although
in a normal stage of development, inadequately prepared
to contend against the operation of external agents. The
respiratory and circulatory organs of an infant under these
circumstances are ill-suited to the proper aeration of the
blood, and its due transmission throughout the frame; the
alimentary organs cannot yet he perfected for the elabora¬
tion of chyle, and the incomplete development of the ner¬
vous system must interfere with the assimilation of nutri¬
tive matter for the wants of the economy. It cannot oc¬
casion surprise that altered function, congestion, or disease
of the most susceptible of the infant’s organs, those of the
nervous system, should occur. Hence the production in
some cases of transient muscular contraction, convulsions,
and death; and in others of permanent spastic contractions
in various parts of the body, succeeded by the forms of
contracture under consideration.

[Of twenty-four more recent cases of general spastic
rigidity of limbs occurring amongst private patients, of which

the author has preserved notes, there were :

Reputed to be congenital.7.

Ditto non-congenital.5

Doubtful, or not observed until period of ordinary wlaking . 11
Reported to have been bom at seventh month of gestation . 8

Ditto ditto at eighth month ..4

Labour difficult, protracted, or having required instrumental

aid in ... .7

Asphyxiated, or semi-asphyxiated, from half an hour to two
days; convulsions usually accompanying or succeeding . 7

Attributed to difficult dentition.3

Numbers equally divided between the sexes.

pronounce each, letter of the alphabet, and knows the majority of them. He can also
count up to 40, repeat the Lord’s prayer, and a verse or two of hymns, with but little
assistance. His health is at present good. He bleeps well, and eats heartily. His body
is in good condition, and well formed; and there is no malformation about the spine
or limbs. During the last twelve months he has been rapidly improving.”

July 29th, 1851. The author’s journal states he is now between five and
six years of age, a favourable instance of this severe class of case. The right
side is most affected. Although he walks in the manner of T. equinus, the
feet can be flexed with the hand. The left hand appears little affected, in the

118

ANALOGUES WITH SPASTIC RIGIDITY.

A large proportion occurred in the mothers’ first preg¬
nancy. Several of these children weighed at birth only
about forty ounces. In several an hereditary tendency to
disorder of nervous system could be traced; as, for ex¬
ample, a parent having suffered from epilepsy or hemi-
phlegia. The family tendency was sometimes shewn by
brothers and sisters having analogous diseases. In half the
cases the affection appeared equal upon both sides; in six
the left side was more affected; and in the remaining six
the right side suffered in a greater degree.

If the analogy between the spastic contraction which
induces these contractures with the muscular contractions
occurring in chorea, hysteria, epilepsy, and tetanus be re¬
membered, the correctness of the rationale of the produc¬
tion of these contractures which I have given will, I believe,
appear conclusive. Certainly chorea, hysteria, and even epi¬
lepsy, more frequently depend on exhausting influences
maintained upon the nervous system, or on impaired as¬
similation of food, and consequent derangement of circula¬
tion and nutrition of the nervous centres (asthenic causes),
particularly if the individual has derived any peculiar sus¬
ceptibility of these organs from the parent, or otherwise
acquired it, than on other causes which seem to act in a
more sthenic manner. This opinion of the mode of pro¬
duction of congenital spastic contractures may he sup¬
ported by the consideration of the frequency with which,
during foetal life, disturbance and disease of the brain and
spinal cord is evinced by more serious phenomena than a
contracted state of the limbs. It is known that a condition
analogous, if not identical, with the serous effusion into the
membranes of spinal cord, brain, and ventricles, which
occurs during infantile life, is produced during embryonic

right pronation preponderates oyer supination; the flexors are less trouble¬
some than pronators. The father’s report, Dec. 1852, is, “ that he has men¬
tally much improved; writes with right hand on a slate tolerably well; but
being obliged to use so much force (to overcome the spasm), he does not do
so well on paper.”

SPASMODIC WRY-NECK.

119

development. The accumulation of fluid in the nascent
cavities and envelopes of the brain and spinal cord (foetal
hydrocephalus, hydrorachitis) operates destructively by dis¬
tension of the delicate textures of which these organs are
composed, causing in some cases the abnormal condition
denominated spina bifida, in others atrophy of a cerebral
lobe, or of an entire hemisphere, or of a lobe of the cere¬
bellum ; and occasionally annihilation of the whole cranial
vault and cerebral contents (hemicephalus, acephalus). In
many instances these extensive arrets de developpement,
as the abnormal states in question are not very appro¬
priately called, co-exist with deformities of the limbs, as
club-hand, club-foot, &c., and other malformations. In
such cases the deformity of the limb has probably pro¬
ceeded pari passu with the cerebral disorganisation.

There is no form of contracture more interesting than
that of wry-neck (non-congenital), sometimes affecting the
s^erao-mastoideus only, as in fig. 29, at other times involv-

Non-congenital ■wry-neck from spastic contraction of sterno-eleido-mastoideus.

ing the clavicular portion of the muscle, as in fig. 35; in

120

PARALYTIC CONTRACTURE.

which case the continued traction exercised by the muscle,
besides producing obliquity of the head and distortion of
the cervical portion of the spine, distorts the clavicle itself.
Usually, when the deformity has long existed, the muscle
is structurally shorter and atrophied, incapable of being
elongated by the hand of the observer; sometimes, how¬
ever, as when the morbid action of the muscle is truly
spasmodic, convulsive, or intermittent, the nutrition, and
consequently the size of the muscle, remains natural, or
even hypertrophy, as in fig. 29, may ensue. In these con¬
vulsive cases the muscle may be stretched out by the ob¬
server, and the deformity be momentarily removed, the
head relapsing on withdrawal of the replacing force. They
are accompanied with distressing jerking movements of
the head, often so severe as to require the support of
the patient’s hands—a state of things rendering retirement
from society necessary. Paralytic wry-neck is rare,—see
case, p. 122.]

Contracture from Paralysis

offers many analogies with that arising from spastic con¬
traction of muscles; for notwithstanding the proximate
cause may appear so opposite, it is often
very similar, if not identical, in external
form. One reason of this similarity is,
that whilst the flexors, adductors, and
pronators are more obnoxious to spasm,
the extensors, abductors, and supinators
are more liable to paralysis. For ex¬
ample, deformity from paralysis of the
extensor and supinator muscles of the

hand. Shortening of the arm is the most Common form of para-
flexors and pronators. lytic contracture in the upper extremity.

And on the loss of power of the peronei and long extensor
muscle of the toes (with which, as an exception to the or¬
dinary law of association, paralysis of the anterior tibial

Fig. 36.

EXTENT OF PARALYTIC CONTRACTURES.

121

muscle is often associated), the muscles of the calf, posterior
tibial muscle, and flexors of the toes, deprived of antago¬
nists, gradually contract. Structural short¬
ening, and atrophy of the fibres result,
and by elevation of the heel and inver¬
sion of the toes, produce as perfectly form¬
ed talipes varus as that resulting from
spastic contraction of these muscles. It
is needless to multiply instances at pre¬
sent, as I shall hereafter consider the
contractures of the individual articula¬
tions.

A further analogy is offered by the
circumstance that paralysis, like spasm,
may induce contracture by’affecting a sin¬
gle muscle or the associated muscles of
one articulation ; those of several articu- Paralytic Talipes varus,
lations of an extremity, or of an arm and f th Hm * lar f form of

J _ knee-contracture.

leg, or of both lower extremities. Para¬
lytic deformity is rarely so extensive as that from spasm ;
thus paraplegia may have been the original affection, and
contracture of every articulation of the lower extremities
have resulted ; but I have once only seen paralytic contrac¬
tures in both the upper conjointly with both the lower ex¬
tremities.* The entire system of voluntary muscles may
have been originally paralytic, contracture having ensued
in those parts only in which the paralysis has lingered.

I have witnessed paralytic deformity in both lower ex¬
tremities conjointly with the left arm, restoration of the
right arm having probably been facilitated by the habitual
endeavour of the individual to use it, or from the primary
paralytic lesion having been less severe. It occurs very
frequently in one hand and arm, in which case the sym¬
metry of the entire frame is disturbed, as from spastic

* This was written, ten years ago, since which the author has seen other
instances.

122

CONGENITAL PARALYSIS.

contracture. More complete atrophy is usually exhibited
in paralytic than in spastic deformity, the vegetative func¬
tions of the paralysed parts, nutrition, and the generation
of animal heat, being greatly impaired, probably in con¬
sequence of participation by the organic nerves in the mis¬
chief inflicted on the voluntary motor filaments.

Even in spastic deformity the temperature of the part
is depressed; but this, as well as the diminished growth,
appears to be less the result of any direct infringement of
the functions of the organic nerves than of a want of the
normal voluntary activity of the muscles, by which the ac¬
tive performance of the functions of nutrition is sustained.
The impairment of the organic functions of the part is in¬
direct.

An important difference between paralytic and spastic
contracture is, that however complete and sudden the attack
of paralysis, the resulting contracture is always gradual.

[Congenital contracture from paralysis very rarely occurs.
I have witnessed only three undoubted cases of this na¬
ture. Paralysis succeeded by contracture has now and
then appeared to arise before or at the moment of birth,
in the same manner as spastic rigidity.* Paralytic stra¬
bismus and mis-enunciation sometimes co-exist.]

Some remarkable peculiarities in the history ofpara-

* The following is a case of paralytic relaxation of entire voluntary mus¬
cular system after asphyxia neonatorum, with small amount of contracture, for
the early history of which the author is indebted to Dr. M'Intyre, Odiham,
Hants.

“ Mrs. **** was taken in labour of her second child at 2 o’clock a.m., Oct. 25,
1843; Mr. *** being in attendance. Breech case. The pains recurred regularly, gradually
increasing in frequency and severity until a quarter past 1 a.m., when there being con¬
siderable difficulty in delivering the head, I was sent for. By the time I arrived I found
it had been accomplished ten minutes, that the child was in a state of asphyxia, and that
a slight gurgling was heard in its throat immediately after its expulsion. It was laid
aside as dead. The limbs were flaccid, pale, and cold, as also the body; and the head,
(from the traction, I supposed) was preternaturally movable. I proceeded to resuscitate
it in the usual way by artificial inflation, warm bath, brandy externally, and frictions,
certainly with very faint hopes of a favourable result. However, after about fifteen
minutes, a slight fluttering could be felt in the cardiac region, and a continued use of the
same means gradually improved its condition. This management was persisted in for
an hour and a half, with occasional short intervals when the heart’s action seemed pretty

SPASTIC AND PARALYTIC CONTRACTURE.

123

lytic and spastic contractures occur, the study of which is
of great interest. Thus you
may sometimes meet with para¬
lysis of peronei and anterior
muscles of one leg attended with
contracture similar in form to
talipes varus, or T. equino-va-
rus, the opposite leg of the same
individual being affected with
the contracture similar to tali¬
pes calcaneo-valgus from paraly¬
sis of gastrocnemii and anterior
and posterior tibial muscles;
the paralysis having affected the
abductors and extensors (“ flex¬
ors of the ankle” of some anato- Paralytic Talipes equino-varus.
mists) in one limb, the adductors and flexors(“ extensors of
the ankle” of some anatomists) in the opposite member.

Before I proceed, it is necessary that I should briefly
explain the form of contracture to which I have assigned

strong, and resumed when it began to flag. At the end of two hours the breathing was
tranquil, but weak. At 4 o’clock .p.m. it cried a little, afterwards sipped a little sugared
water, and in the evening cried most lustily.

“ 30th. During the second and third flays it had frequent convulsions, slight in cha¬
racter, affecting the whole body, accompanied with heat of head; and in the intervals
was restless and fretful. Two leeches were applied to the head; cold affusion whilst in
a warm bath, and a grain of calomel, followed by a drachm of castor oil were given, and
acted freely. Cold applications were continued until the 30th (to-day), the heat of head,
though diminished, being still above natural. Has had no convulsions since the 28th, and
upon the whole is improved. Has not sucked. Bowels confined, for which this morning
had an enema of ol. terebinth, half a drachm, mucilage three ounces, which acted freely.

“ Nov. 10. No return of the convulsions; but an obstinate and protracted diarrhoea su¬
pervened, followed by great debility and emaciation, supposed to have arisen from the
mother having taken much aperient medicine. It has now, however, much improved.”

The author, in his journal, April 1847, thus describes it.

“ Laxity of neck, head having inclined to right shoulder since birth; right stemo-
mastoid muscle weaker than left; chin not so much rotated as entire head inclined to
fall to the right shoulder; the whole of the limbs feel relaxed, without contracture or
absolute paralysis; tendency to pronation of hands; can support herself against a wall;
falls if her attention be abstracted; can utter a few words, and she looks intelligent;
deglutition of fluids difficult.

“ Nov. 1849. Considerable improvement, although some contracture of adductors of
thighs has taken place; walks, the hands being held, and leaning with front of her body
against attendant; can stand against sofa; the knees cross; intellect developing, when

124 NATURE OF TALIPES CALCANEO-VALGUS.

the name talipes calcaneo-valgus. It is that species of
claudication and deformity in which the individual walks

principally on the
calcaneum or
heel, the toe be¬
ing at the same
time turned out¬
wardly, as in val¬
gus.

Youmay some¬
times observe this
contracture ofT.
calcaneo - valgus
in one foot from
paralysis [of cer¬
tain muscles,
complete or par¬
tial], whilst T.
varus may exist
in the opposite
limb from spastic
contraction; or
you may witness
the spastic, non-

and posterior tibial muscles, a. The internal malleolus ; congenital T. Va-
b. the projecting astragalus; c. the outer margin of foot .

raised from the ground. rus in the left

foot, the right

limb of the same individual being affected with complete
paralysis of the whole of the muscles, without any con¬
tracture.

requested can give either hand or foot; spells a few short words; knows persons and
places; has feeble but correct use of hands.

“ April 1852. Much contraction of adductors of thighs ; chorea-like movements.”

This case is further interesting by its suggesting the possible dependence
of the asphyxia, convulsions, and paralytic debility upon mechanical injury to
the neck at birth.

Fig. 39.

LECTURE VIII.

Contracture and causes—Nature of lesion in nervous centres in spastic
and paralytic contracture—Mechanical injury to nerves — Conco¬
mitant disturbance of functions of sensorium — Spastic rigidity in
newly-born infants — Morbid anatomy of contractures — Organic
changes of articular surfaces do not necessarily follow prolonged
repose of the member — Restoration of largest articulations after
many years’ contracture possible — Description of anatomical con¬
dition of knee contracted twenty-five years from paralysis ■—Absence
of insuperable obstacles to cure—General treatment of contractures.

The observation of a large number of cases of contracture,
in tbe production of which spasm and paralysis have been
the efficient agents, more particularly the simultaneous
occurrence in the same individual of both these diseased
conditions, leads to the conclusion that the nature of the
primary lesion in the central organ is the same in either
case. The origin of one class of spasmodic contractures
through a chain of incident and reflex phenomena, has
been already described; the remaining spastic contrac¬
tures, as well as the paralytic cases, whether congenital
or not, arise from disease in the brain or medulla spinalis.
Probably in the majority of instances the medulla spinalis
is alone affected [?]. Contracture from spasm, or paralysis
of a single muscle, of a. set of associated muscles, or of the
entire muscular system of an extremity, depends upon func¬
tional derangement or organic alteration in the central
organ, limited to the roots of a proportional number of
filaments of nerves distributed to the extremity. From
the pathology of spasmodic diseases in general, it may be
inferred that a higher degree of injury to the delicate fabric
of the nervous tissue, or of the investing membranes, is
required to produce paralysis of muscles than spasm. The

126 PATHOGENY OF SPASM AND PARALYSIS IDENTICAL.

lesion is, in most cases, inflammation, chronic or acute,
in either of its stages of congestion, effusion, or softening.

From the analogy offered by many spasmodic affections
in their frequently transient nature, the smaller amount
of atrophy accompanying spasmodic contractures, and the
occasional occurrence of spasmodic contraction in an ex¬
tremity as recovery ensues from complete paralysis, we
may suppose that the slightest of the morbid changes in
the condition of the capillaries of the nervous tissues or
membranes—relaxation or congestion—may excite spastic
action of muscles, and that the ulterior changes of effusion
and softening induce sufficient compression and disor¬
ganisation of the nervous tissue to effect paralysis.* Mor¬
bid anatomy has not yet clearly revealed whether slight
congestion of the spinal veins may not suffice to produce
that degree of disturbance of the medulla from which con¬
tracture arises. It is demonstrated that an adequate con¬
gestion of this nature may produce paralysis.

In order to test the accuracy of this opinion, it can
scarcely he objected that, if correct, paralysis, when gra¬
dual in its occurrence, should invariably he preceded by
spasm; for, although relaxation of capillaries in a par¬
ticular part of the central organ he adduced as the pro-

* In order to illustrate the dependence of spasm and paralysis upon dif¬
ferent degrees of activity of the same proximate cause, or of the same morbid
action (convertible terms), the author may relate an uncommon case which
fell under his observation, in company with Mr. Tidy of Hackney, during all
its stages. A robust male child, aged four years, was seized with severe
rheumatism; in a day or two the symptoms reached an unusual intensity;
the face presented so great anxiety as to suggest cardiac affection, which was
disproved by physical examination of the chest. The child referred the
greater part of his sufferings to the back; and it was noticed that the thumbs
were drawn into the palms. Rheumatic spinal meningitis was diagnosed.
Convulsions supervened; these, after several paroxysms, were succeeded by
total paralysis of all the members. In a few days he began to rally, power
was gradually restored to the limbs ; but as the paralysis disappeared, con¬
traction of flexors and adductors of lower extremities, and of the flexors and
pronators of the arms, shewed itself.

NATURE OF THE LESION IN NERVOUS TISSUE. 127

bable cause of spasm, it does not follow that spasm should
necessarily result from such relaxation, since it may be re¬
garded as an occasional consequence only of that morbid
change. Even the assertion that the morbid change in
the nervous tissue which induces the perplexing pheno¬
mena of the spasmodic diseases in general depends on re¬
laxation of the capillaries, is an assumption founded only
on our ignorance of any other cause than inflammation*
capable of producing the effects we witness, and on the
opinion that relaxation is the physical change which takes
place in the capillaries during that process.

Many pathologists suppose that the opinion of a simply
dynamic change in the condition of the ultimate fasciculi
of the nervous centres will suffice to explain the occur¬
rence of involuntary muscular contraction,—such, for ex¬
ample, as chorea, hysterical contraction ; and it might be
inferred that the same hypothesis will apply to the primary
origin of the spastic contraction under consideration. It
is probable that an altered dynamic, vital or electroid in¬
fluence, is the first in the series of phenomena manifested
in spastic contraction ; but in the present state of pathology
this dynamic change can be presumed to produce its effects
only by influencing the capillaries, as respects their action
or tonicity, and their size.f

It cannot be doubted that when hysterical or other
contractures have ceased to be transient, but have existed
many weeks, months, or years, something more than a
dynamic or functional change in the nervous centres has
ensued. Relaxation, congestion, or other more consider¬
able organic changes will have succeeded. You should,
however, bear in mind, that after the lapse of time the

* By inflammation here is to be understood any of its numerous phe¬
nomena, stages, and phases. (See Principles of Medicine, by Dr. Billing.)

f This Lecture was delivered in 1843, before the discovery of the great
share in pathological processes exercised by abnormal cell-nutrition was recog¬
nised. The author thinks it unnecessary to discuss what amount of influence
in these disorders may also be exercised by morbid states of the blood.

128

CONTRACTURE FROM INJURY OF NERVE.

lesion in the nervous centre may have entirely subsided,
the deformity being solely maintained by structural short¬
ening of the muscular structures.

Mechanical injury to a nerve in its course to an ex¬
tremity may excite permanent contraction of the muscles
to which its filaments are distributed, and a contracture
may result. Delpech relates a case of talipes equinus
caused by an inj ury of the ischiatic nerve from a gun-shot
wound. I have recently had under my care a contracture
from a similar cause in the person of one of the brave
defenders of Kelat, in A Afghanistan. [The gentleman in
question received a sabre wound, which involved the bi¬
ceps tendon, the head of the fibula, and the peroneal
nerve. Paralysis of anterior and external muscles of the
leg ensued, and the posterior muscles, deprived of antago¬
nists, gradually produced rigid contracture of ankle, eleva¬
tion of heel with inversion of foot (T. equino-varus).]

Compression of the spinal nerves as they emerge from
the vertebral canal, resulting from deformity of the ver¬
tebral column, may induce spasmodic and paralytic con¬
tractures of the upper or lower extremities, according to
the situation of the deformity. The spasm or paralysis
may also result from pressure upon, or through production
of organic changes in the medulla itself.

A common origin of these contractures is insensibility
(coma) in infancy ; either preceded by visible indisposition,
as fever, diarrhoea, convulsions, or occurring suddenly
(apoplexy), without premonitory symptoms. Sometimes
the insensibility continues for many days, being succeeded
by perfect paralysis of the entire voluntary muscular sys¬
tem. This usually subsides into hemiplegia, and subse¬
quently wholly disappears, or contraction or paralysis of
the muscles of an extremity or of several limbs remains.

Morbid Anatomy of Contracture in general.

Few opportunities have been afforded me of investi-

THE ARTICULATIONS IN CONTRACTURE. 129

gating, by dissection, tbe organic alterations in articu¬
lations contracted during many years, by causes that
have operated at a distance from the articulations. It is
regarded almost as an axiom in pathology, that if any
portion of the frame remain long in a state of inactivity,
it will at length become so changed in its structure as
to be incapable of resuming its functions. The appli¬
cation of this doctrine to contracted articulations has led
to the assumption that, after the lapse of an uncertain
period, the synovial surfaces undergo a gradual change of
structure, the secretions become vitiated and diminished,
and that adhesion of the articular surfaces, and, finally,
complete ankylosis, result. I shall hereafter relate some
circumstances which invalidate the accuracy of this opinion.
I have already expressed my disbelief in the production of
ankylosis simply from a state of rest. The prevalence
of the error is in part attributable to the absence of
discrimination between joints rigidly contracted and im¬
movable by disease within or among the structures of the
joint itself (ankylosis), and those contracted from causes
operating at a distance, and consequently in an indirect
manner only on the joint, constituting contracture. "With
the assistance of this distinction in the characters of con¬
tracted joints, observable during life, the morbid anato¬
mist would necessarily seek, after death, for organic altera¬
tions in the first class of cases, and would infer the absence
of similar lesions in the second class.* It is not impossible
that an articulation, rendered inflexible from the causes
of contracture, may, although not primarily damaged, sub¬
sequently become subjected to the operation of causes ca¬
pable of injuring the integrity of the tissues. Thus the
muscles surrounding the articulation may possibly, by reason

* “ II faut bien distinguer la rigidite articulaire de l’ankylose, qu’elle
simule. . . Si les malades succombent, on est tout surpris de trouver les sur¬
faces articulaires intactes, alors qu’on croyait a une reunion solide des os.”—
Cruveilhier, Anatomie Pathologique, liv. 34. (See note, p. 104.)

Posterior aspect: a , femur
internal condyle; c, ditto i
surface of internal condyle,
ascular attachments to tibia and fibula; l,
corresponding divided portions of capsular
$, tense crucial ligaments.

SHORTENING OP LIGAMENTS.

of the contracture, act so unequally on the articular ex¬
tremities, that the reciprocal adaptation of one hone to
another may be destroyed, and the investing cartilage
suffer from the effects of friction, and abrasion result. But
although the possibility of this occurrence cannot be de¬
nied, the restoration to function of the largest articulations
of the frame after long-continued contracture leads strongly
to the conclusion that these secondary lesions do not take
place.* The preceding figures (figs. 40, 41, pp. 130, 131)
represent the anatomical condition of a knee-joint which
had for twenty-five years been rigidly flexed from paralytic
contracture, j-

You will perceive from this preparation that the only
perceptible alteration from the normal condition of the
articulation consisted in structural shortening of the ex¬
ternal lateral and the crucial ligaments. This was suffi¬
cient, after removal of the resistance of the muscles, to
maintain flexion of the articulation: but gentle pressure
with the hand demonstrated the elasticity of these liga¬
ments, and that the shortening of their fibres was inade¬
quate to prevent straightening of the articulation on appli¬
cation of very moderate force. The relation of the tibia
to the femur was that of outward rotation on the perpen¬
dicular and transverse axes, as in ankylosis. The influ¬
ence of the crucial ligaments, when shortened from long-
continued flexion of the articulation, in maintaining and

* In incomplete ankylosis the effects of friction are often visible, pro¬
bably in consequence of the previous disease of the articulation having di¬
minished the resisting powers of the articular surfaces.

f I am indebted to the kindness of Mr. Gay for the use of the prepara¬
tion from which the drawings are taken. This gentleman’s report of the case
is as follows : “ W. R., setat. 26, died of fever at the Royal Free Hospital in
September 1840. He was born with perfect use of the limbs, but at the
age of six months lost the use of the right lower extremity (from bad nursing),
according to the report of his friends. He did not afterwards shew any dis¬
position to use that limb, and until the time of his death walked upon the
other leg and a crutch. The knee-joint became perfectly fixed, the leg and
thigh being at a right angle.”

MORBID ANATOMY OF TALIPES CONTRACTURE. 133

probably in increasing the above rotation, may be studied
in this figure. It appears incontestable that the peculiar
arrangement of these ligaments (see r, s, fig. 40), their di¬
rection from the posterior part of the tibia and external
portion of the fibula to the anterior and external surface
of the interna] condyle, favours the rotation of the tibia,
on which, owing to its practical importance, I have so
much insisted in the lectures on deformity from angular
knee-ankylosis (pp. 78, 84). Other opportunities of exa¬
mining contractures after death have afforded the same
results.

[The London Hospital Museum contains a dry pre¬
paration of the bones of a foot in the position of extreme
Talipes equinus, probably derived from a subject who had,
during a long life, laboured under paralytic or spastic foot-
contracture.

The ordinary form of the foot affected with this distor¬
tion suggests at once that it cannot be accompanied with
any irremediable deviation from the natural form and
arrangement of the tarsal bones. The preparation in ques¬
tion (fig. 41) shews the deficient development of the osseous
framework in all its parts, but no positive displacement or
dislocation of any particular bone. Owing to the extended
position of the foot, the surfaces of the astragalus, which
should articulate with the tibia and fibula, are exposed upon
the dorsum pedis, and, as well as the articulating surfaces
of the tibia and fibula, have lost much of their natural
smoothness in consequence of little or no motion having
taken place between them. The os calcis during life-time
had been drawn so much upwards behind the tibia as to
have touched it; consequent upon which, a new articular
surface is visible upon the superior part of the calcaneum,
close to the articular surface for the astragalus. The dor¬
sum pedis is much more convex than in a natural foot,
owing to the scaphoid, together with the cuboid, cuneiform,
and metatarsal bones being drawn towards the sole; hence

134

MORBID ANATOMY OF

the round head of the astragalus is exposed, instead of
being covered with the hollow of the scaphoid bone, as in a
healthy state. The individual bones are imperfectly de¬
veloped or have undergone atrophy.

The altered position of the bones in T. varus is more
complicated than in T. equinus, which might have been ex¬
pected on a comparison of the symptoms of the two diseases
in the living subject. Non-congenital Talipes varus pre¬
sents us with all the anatomical characters of T. equinus,
with the addition of others which depend on the adduction
and rotation of the foot. The os calcis is drawn upwards;

Fig. 42.

Arrangement of bones in non-congenital Talipes equinus. It represents the probable
anatomical disposition of the bones in cases such as fig. 38. The extreme incurva¬
tion of the sole had resulted from the protracted contraction of the plantar struc¬
tures, favoured by the individual never having applied the sole to the ground. Use
of the foot could only have been obtained by -walking upon dorsal surface of tarsus
and metatarsus. The subject of the preparation had effected locomotion with the
assistance of a wooden leg applied to the knee.

raid be obtained. It is doubtless the result of non-congenital
foot. It may be relied on in the study of the anatomical cha-
; as, from the evaporation of the spirits of wine from the jar

was completely dried up, resembling
ice the author was enabled (by soaking
od by subsequently removing as much
ry) to expose the hones for examination
Iteration of the relative position of those of the tarsus having

* In the first edition of Treatise on Club-foot, £(c., the author proposed
to employ the term Talipes (previously applied to varus only) as a generic
one, to include all the varieties of foot-deformity produced by muscular con¬
traction. His example has been followed in general use. Talipes therefore
includes contractures and congenital distortions of feet.

136

TREATMENT OF CONTRACTURES.

navicular bone occasionally touches the internal malleolus,
and has an articular surface formed on it, occasioned by con¬
stant friction (see fig. 43). The superior or external sur¬
face of the os cuboides is somewhat separated from that of
the os calcis; whereas the plantar surfaces of these two bones
are turned towards each other, leaving a triangular space
between them externally. The course of the tendons of
the muscles situated upon the front of the leg is conse¬
quently much altered. Those of the tibialis anticus, ex¬
tensor proprius pollicis, and ext. long, digitorum, more par¬
ticularly the first of these, are deflected so much internally,
after passing over the ankle-joint, as to serve by their action
to increase the deformity in the living subject (see fig. 43).

The morbid anatomy of the muscles and ligaments in
contracture may be summed up in the evidences of struc¬
tural shortening, atrophy, and degeneration, presented in
common with other long-standing distortions already de¬
scribed, p. 17.]

In addition to the testimoy nderived from pathological
anatomy, the result of the application of curative measures
proves the absence of organic alterations in joints affected
with contracture. From examination of the numerous
models around you, representing limbs affected with these
deformities, and their condition after the cure, you will
comprehend the important fact, that articulations which,
during twenty or more years, have been rigid, almost im¬
movable, and wholly unserviceable, through contraction of
the surrounding structures, may, on removal of the con¬
traction, be restored to their functions.

Treatment of Contractures in general.

A little reflection on the pathology of contractures will
suggest to you the indications of treatment. When cer¬
tain muscles are spastically contracted, and the contracture
is recent, the resources of medicine available in spasmodic

TENOTOMY IN CONTRACTURE.

137

diseases in general must be resorted to, counter-irritation
to the spinal column, laxatives, mercury, iodine, iron,
arsenic, &c. You will bear in mind the tendency to struc¬
tural shortening of muscular fibres and other tissues, and
adopt those means of preventing this result of continued
contraction which I have already described (pp. 49, 51, 73).

The indications in contractures of long duration are
several. You have, in the first place, to remove the struc¬
tural shortening of muscles by mechanical extension or by
division, as in the treatment of deformities from articular
disease ; secondly, you have to effect the replacement and
mobility of the parts; and, thirdly, to restore the power of
volition in the debilitated muscles as well as in those which
preponderate. [In some contractures, spasmodic action of
the implicated muscles exists without structural shortening,
as in certain cases of wry-neck (p. 119), in hysterical con¬
tractures generally, and often in Talipes. On failure of
medicinal and general treatment, the question of the pro¬
priety of having recourse to subcutaneous tenotomy arises.
In some distortions the aid of the operation is needed for
the purpose of preventing secondary deformity, such as that
which is apt to arise in the growing person from walking
upon a limb in a distorted position. But a liability to re¬
lapse, or to the occurrence of a deformity of an opposite kind,
should not be overlooked (p. 148-9). In general, however,
in accordance with the rules already laid down, tenotomy
is only advisable when structural shortening of muscle,
insuperable to legitimate mechanical treatment, exists.*
The question is sometimes to be determined by the surgeon
who is practically experienced in the employment both of
mechanical and operative treatment, taking into considera¬
tion the relative amount of pain endured, and time employed
in the two methods.] The means specially applicable to
the individual contractures will occupy the next lecture.

* For the mode of performing subcutaneous division of sterno-mastoid,
see Congenital Wry-neck.

138

LECTURE IX.

Characters of spastic rigidity of muscles and deformity in infants, young
children, and adults—Treatment — Spastic deformities of ankle —
Non-congenital club-foot; origin, symptoms, and treatment—Spastic
contracture of hand and arm — Universal paralytic deformity of upper
and lower extremities — Treatment—Value of tenotomy in contrac¬
ture of elbow and wrist.

The first contracture which I shall consider is that result¬
ing from universal rigidity of the muscular system, or of
the flexor muscles only, in new-born infants; a condition
analogous to trismus nascentium, a .common disease in cer¬
tain tropical countries.

In some instances the rigidity of the limbs is imme¬
diately apparent, in others it escapes observation during
several weeks or months, or the spastic rigidity becoming
complicated with structural shortening of the tissues on
the contracted sides of the articulations, the nurse observes
that she is unable to wash and dress the infant with the
ordinary facility. The knees cannot be properly separated
or depressed. Sometimes the trunk is stiffened, so that
the infant is turned over in the lap “ all of a piece,” as the
nurse expresses it. Occasionally the head is habitually
retracted, and the elbows and wrists participate in the in¬
flexibility. Very frequently the contracture is confined to
the lower extremities, but more rarely to a single limb.
The infant is observed invariably to sleep with the knees
firmly approximated to the abdomen and to each other,
and the toes inverted. As the child approaches the period
at which the first attempts at standing and progression
should be made, it is observed to make no use of the limbs;
a consultation with the medical practitioner ensues, and
a paralysis is sometimes pronounced to exist. In cases

SYMPTOMS IN INFANTILE SPASTIC RIGIDITY. 139

where the sensorial part of the .brain has suffered con¬
jointly with the medulla spinalis, the intellect may even
thus early be observed to be less developed than usual.
The inability to stand or walk continues until perhaps
the age of three or four years,
when, with assistance, the child
contrives to support himself. It
is now ascertained that the soles
of the feet are not properly ap¬
plied to the ground, that the
knees always incline inwardly,
and that they continue bent. The
child at length effects locomotion
unassisted; but he cannot be said
to walk, as his movements are
characterised by an inability to
stand still and balance himself
erect. In the endeavour .to do
this he commonly falls, and to
avoid this accident requires to
continue in an imperfect running
until he meets an object against
which he can support himself.

Being unable to bend the ankles,
the toes strike against the smallest
irregularities on the surface, oc¬
casioning loss of balance and frequent falls. In process
of time greater certainty and ease in locomotion may be
spontaneously obtained.

[The child often manifests uncommon sensitiveness to
impressions; even when approaching adolescence, he is
alarmed at trifling noises. The sleep is usually light, easily
disturbed. This nervous susceptibility often reminds the
observer of the condition of a tetanic patient.

The inability to stand or walk firmly is due in part to
shortening of the gastrocnemii and other muscles, the in¬
dividual being, through the consequent elevation of heels,

Fig. 44.

Mode of progression in an adole¬
scent affected with congenital
spastic rigidity.

140

CONTINUED SPASM INCOMPATIBLE

deprived of the extensive basis of support afforded by the
planta pedis, and in part also to the deficiency of voli¬
tion exercised in the muscles concerned in progression.
In many morbid states of the nervous and muscular systems
a similar inability to perform slow, measured, or steady
action of muscles is manifested ; a greater amount of nervous
power being requisite to perform a single, complete, well-
ordered action than to effect a number of incomplete move¬
ments. Thus, in lameness generally, when independent of
physical obstacle or considerable paralysis, progression is
quickly affected. In “nervousness,” in stammering, in
chorea, in delirium tremens, in fever, a similar condition
exists. Aberrations of the mental power present analogous
conditions, and are often coexistent with aberrations of
volition. The relaxed, enfeebled intellect more readily
originates a number of thoughts than carries any one of
them to completeness.]

The same form of contracture may be produced later in
life, during dentition, or during any of the numerous dis¬
eases of infancy, which excite much general disturbance.

I have treated two cases in adults in whom the spastic
state of the muscles resulted from direct mechanical injury
applied to the spine; and two others, in which the uni¬
versal contracture of the lower extremities resulted from
disease, and deformity of the vertebral column.

You will remember that a single member may be thus
affected ; the case is still less unfortunate when the con¬
tracture does not involve the hip-joint, but is confined to
the knee and ankle.

. Treatment of general spastic rigidity. — During the
earlier months of existence you can resort to few thera¬
peutic measures. I have usually contented myself with
directing the nurse several times daily to endeavour to
straighten the flexed articulations; and this may generally,
after a little perseverance, be accomplished, the object
having been to prevent structural shortening of the spastic
muscles. But from the observation of the utility, at a later

WITH MUCH STRUCTURAL SHORTENING.

141

age, of counter-irritation to the vertebral column, I am in¬
duced to recommend you to try the use of stimulant embroca¬
tions to the back. Of course you will not neglect attention
to the digestive organs, the proper action of which is of
equal, importance in health and disease. From the age of

twenty months and upwards,
I have employed more ac¬
tive counter-irritation to the
neck and loins, lytta, potassa,
and repeated small issues pro¬
duced by argentum nitra-
tum. You may endeavour,
by appropriate mechanical
apparatus, such as that re¬
quisite in deformities from
other causes hitherto con¬
sidered, to effect elongation
of contracted parts; but the
primarily spastic nature of
the muscular contraction will
prepare you for greater re¬
sistance, and perhaps con¬
vince you of the hopeless¬
ness of the attempt to effect
mechanical elongation. It
will, however, in many cases
be evident that the primary
cause in the nervous system
has subsided [or the muscular
fibrils have undergone trans¬
formation], and that you

Fig. 45.

Non-congenital spastic contracture of hips,
lcnees, and ankles. When unassisted by
art, the individual, with advancing years
and increasing weight, becomes less able
to effect locomotion without crutches.

have structural shortening alone against which to contend.

Failing manipulations, instruments, and the remedies di¬

rected against the cause of the contraction resident in the

nervous system, you still have tenotomy as a dernier ressort;
and this, in the majority of instances, will not disappoint
your expectations (p. 187).

142

NON-CON GENITAL TALIPES.

The parts requiring section here may be the adductors
of the thighs, the hamstrings, gastrocnemii, and adductors
of the feet. I can scarcely limit the age at which this ope¬
ration may not be productive of benefit. There is the
drawing (fig. 45) of an adult upwards of thirty years of age,
who had never walked, but who acquired sufficient power,
after tenotomy and straightening of the limbs, to walk with
the assistance of a stick only. Several similar cases have
been observed in in-patients at the institution. The diag

Fig. 46.

Non-congenital spastic contracture. T. equino-varus. The arrows indicate the direction
of the convexity of the tarsus and metatarsus, forwards and outwards; the perpendicu¬
lar line through the axis of the limb shews the extent of the inward deviation of the
metatarsus, by which the base of the little toe, being brought completely beneath the
axis, has to support the entire weight of the body in walking. Completely restored by
section of T. achillis and mechanical treatment. For minute details of treatment, the
reader is referred to Treatise on Club-foot, 1st edition, Appendix, Case XIII. The indi¬
vidual has remained quite well.

NON-CONGENITAL SPASTIC TALIPES.

143

nosis of these spastic contractures from paralytic contrac¬
tures rests upon the presence of volition in every muscle.
It is necessary to he careful also not to confound them with
similar deformity from disease of the articulations.

Thus far I have principally dwelt on spastic contracture
of the hips and knees. The corresponding affections of
the ankles are more common. As I have already men-

Fig. 47.

deformity. The globular prominence visible upon the instep arises from the expo¬
sure of the round head of the astragalus^ the navicular bone having been drawn from
it both inwards and upwards.

144

VARIETIES OF NON-CONGENITAL TALIPES.

tioned, they invariably accompany the contractures of the
hip and knee, though they often occur independently of
them, and constitute- the spastic forms of non-congenital
talipes, or club-foot. Figs. 46-48.

The most simple form is that consisting of abnormal
spastic elevation of the heel, causing the individual to walk

Fig. 48.

The ‘posterior view of the foot represented fig. 47.

on the toes only; or the deformity may be combined with
some inversion of the toes, as in fig. 46. A complete varus
(figs. 47 and 48) may result from the spastic contraction*of

MODE OF ORIGIN IN CHILDHOOD.

145

the adductors of the foot conjointly with the gastro-
cnemii.

It is necessary that I should impress upon your atten¬
tion the mode of origin of many of these cases of deformity,
as errors of diagnosis are in this respect not uncommon.
In adults the attack can usually be'traced to an epileptic,
hysterical, or chorea-like seizure; in children the deformity
succeeds to an attack of convulsions, but more commonly
the origin is unperceived. It is often stated by the parent
to have been an injury sustained whilst at play; whereas
inquiry elicits the fact that the deformity had not for its
cause an origin of that nature, but arose from disturbance
of the nervous system. It is evident that in many in¬
stances the muscular contraction comes on insidiously, and
does not attract attention until some trifling accident at
play, as a fall (induced probably by the gastrocnemii being
already partially affected with spasm, and imperfectly under
the child’s control), leads to an examination of the limb;
from which period the increase of contraction and deformity
becomes anxiously watched. In the remarks on spasmodic
contractures in general, I mentioned that when the con¬
traction is gradual, the remote cause often consists in chronic
derangement of an organ affecting a peripheral part of the
nervous system. There exists, in my opinion, no cause
more frequently productive of these spastic contractures
of the ankle than derangement of the mucous membrane
of the alimentary canal, indicated by worms, diarrhoea, or
other symptoms of gastric or intestinal morbid sensibility.
This disturbance .may continue a considerable time un¬
heeded, or without suspicion of its tendency to induce
secondary disease being awakened. By means of the chain
of filaments on which the reflex functions of the nervous
system depend, it may be unobtrusively exciting involun¬
tary contraction, evinced by a scarcely perceptible limp, a
tendency to fall, or a certain wayward action in walking.
At this period it frequently happens, that if the foot be

146 CONTRACTURE FROM IMPAIRED NUTRITION.

examined when not actually engaged in walking or stand¬
ing, no abnormal condition can be perceived (unless per¬
chance a slight diminution of the bulk of the limb already
exists); for Stromeyer has shewn, and you will have fre¬
quent opportunities of verifying the observation, that it
is characteristic of this affection of the gastrocnemii (pre¬
viously to its acquiring the highest grade, and having
existed a considerable period when atrophy commences),
to be excited into activity, or much augmented, when the
sole of the foot touches the ground, as in walking. This
may remind you of the effects of irritating or touching the
web of the frog’s foot, or the skin of the sole of the rabbit,
when the excitability of the muscles is increased by nar¬
cotism or decapitation, or the influence of volition removed.
The membrane and skin covering these parts are, like the
skin of the human sole under certain circumstances of dis¬
ease, more particularly susceptible of external impressions,
and when irritated, capable of producing reflex muscular
contractions.

You may bear in mind that impaired nutrition of the
frame, whether it result from disease in an organ, or be
the direct consequence of deficiency of food, is one of the
most active predisposing causes of these deformities, as of
chorea and the whole of the neuroses. Raphania, a disease
not unfrequently witnessed in those parts of the continent
where rye-bread is the principal food of the people, is ac¬
companied with spasmodic contracture of the lower extremi¬
ties ; hence it has been denominated the cripple disease.
The older authors have attributed raphania to the poi¬
sonous action of secale cornutum; but it admits of doubt,
whether the symptoms may not in great measure be refer¬
able to imperfect nutrition [consequent upon the use of the
deteriorated article of diet]. In the oriental disease beri-
bery, in which spastic rigidity of the limbs constitutes so
important a symptom, the patient, after subsidence of the
acute symptoms, remains affected with spastic contracture.

ORIGIN SOMETIMES ACUTE CEREBROSPINAL. 147

I have recently (1841) relieved, by tenotomy, a gentleman
who had been totally incapable of locomotion from this
disease, contracted during a residence in Ceylon many years
since.*

The treatment of these spastic contractures of the ankle,

* The opportunity of studying this interesting case was furnished me by
Dr. Hoskins of Guernsey. The feet were in the position of extreme Talipes
equinus; the patient used crutches, and appeared hopelessly paralysed. Not¬
withstanding the uncommonly rigid tension of Achilles tendons, and subse¬
quent complete depression of the front of the foot, a slight tremulous action
of anterior muscles of ankle was perceived, which suggested the possibility
that the case originally might have been spastic loss of use of limbs, instead
of paralysis, or spastic contraction succeeding to that graver affection, as in
the case narrated p. 126. The Achilles tendons were at once divided; for trial
of mechanical means, unaided by tenotomy, was, in the case of limbs pre¬
senting the bulk and rigidity of the present case, quite out of the question.
In a few weeks he was able to walk without crutches.

The following letter will shew that the relief has been permanent:

Guernsey, December 2d, 1852.

My dear Sir,—It gives me great satisfaction to inform you that Mr. ****
derived the greatest benefit possible from your .... treatment. He can
now stand, amusing himself at his lathe, during the livelong day, and can
take a walk of four miles, over indifferent pavement, without inconvenience
or experiencing fatigue. His left foot turns out; but this is confessedly as-
cribable to his not following your injunctions, after he left you, as strictly as
he ought to have done.

I have shewn him your note, and he requests me to state a fact of which I
was cognisant before he went to London, that there was no degree of paraly¬
sis whatever associated with his infirmity. He could by the aid of his toes
propel himself from room to room in his wheel-chair. He also says that the
complaint under which he laboured in Ceylon, and which gave rise to the con¬
traction, was not beribery, which is accompanied with a swelling of the ex¬
tremities analogous to elephantiasis (?). He never had any swelling.

The original attack was a singular one : I have never been able to make
it out to my own satisfaction. The exciting cause of the contraction was
snipe-shooting in the rice-grounds, up to his knees in water, with a tropical
sun shining on his head for hours.

I am, my dear sir, yours very sincerely,

J. Elliott Hoskins.

This communication confirms the prognosis as to the absence of paralysis.
A doubt exists, whether the affection resulted from beribery or some other
form of affection of medulla spinalis from tropical exposure. See Mason
Good’s Study of Medicine, vol. iv. p. 493, 3d edition.

148

TREATMENT OP SPASTIC TALIPES.

so long as they present a probability of removal by the
general and mechanical means, should be conducted on the
principles already laid down; and when the assistance of
tenotomy becomes requisite, the’section of those tendons
only which offer the greatest resistance should be accom¬
plished, viz. the gastrocnemii, with or without the adduc¬
tors of the foot (anterior and posterior tibial tendons),
according to the peculiar abnormal form of the member.
In those cases in which the ligaments do not retain the
limb in the old position, you will often find that after the
operation the antagonist muscles forcibly endeavour to dis¬
tort the foot in the opposite direction. It is therefore
important to secure the foot, by means of splints, in the
primary deformed position, to prevent too great elongation
of the divided tendons. The deformity can be gradually
removed by subsequent mechanical means, and the func¬
tions of the limb be partially or completely restored by
the same after-treatment described in' the lecture on de¬
formity from ankylosis.

Spastic contracture of the upper extremity rarely occurs
independently of

Fig. 49. r / ,

contracture m the
lower limbs. The
causes are the
same. Tt affects
commonly the pro¬
nators and flexors

Spastic contraction of extensors of wrist. The extensors of f wrists arid

fingers either unaffected or incapable of overcoming the 01 Ule wrlbls > dou
flexors of fingers; the wrist therefore is extended, whilst fingers (fig* 31,
the fingers are flexed.

p. 109), sometimes

the biceps, pectoralis major, latissimus dorsi, teres major
and minor. [Occasionally the extensors or the flexors only
are contracted, fig. 49 and fig. 50.] The treatment should
be based on the same principles as that necessary in the
corresponding affection of the lower limbs. I would not
advise you hastily to resort to tenotomy in these cases.

PARALYTIC CONTRACTURES.

149

I shall defer the consideration of the operation, until
I have spoken of
paralytic contrac¬
tures.

[In concluding
the treatment of
spastic contract¬
ures it may he re- Spastic contraction of flexors of wrist. The flexors of fingers
* being unaffected, the corresponding extensors, being

peated, that teno- stretched in passing over wrist, maintain extension of

tomy is only to be fingers -

resorted to as a dernier ressort on failure, of mechanical
treatment. In spastic contracture tenotomy is only avail¬
able as a rude means of mechanically defeating the per¬
sistent active contraction of the deranged muscles. Some¬
times, even when deformity in the opposite direction does
not result, the relief is not permanent; for if too great
shrinking of the intermediate tissue which unites the se¬
vered ends should ensue, return of the original deformity
may be expected.

In those cases, however, in which the spastic contrac¬
ture has existed many years, structural shortening of the
muscles and tendons will have supervened, the muscular
fibrillae will have become more or less disorganised; so
that whilst the structural shortening will have rendered
tenotomy more necessary, the disorganisation of fibre will
have rendered re-contraction less probable.]

Universal 'paralytic contracture of the lower extremities
presents, at first view, considerable resemblance to the spas¬
tic affection of the same parts. It arises at various periods
of infancy, the organic disease of the central organ of the
nervous system being preceded or accompanied by disorders
of dentition, intestinal derangement, hydrocephalus, fevers
of various kinds, and universal debility. A perfect para¬
plegia or hemiplegia, occurring gradually or suddenly [some¬
times in the night, without previous indication of indisposi¬
tion], are frequent precursors of this contracture. In the

Fig. 50.

PARALYTIC CONTRACTURES.

150

study of tlie origin of these contractures it is apparent that
in many instances the paralysis affects particular sets of the
muscles; the non-paralysed muscles slowly contract, and
produce deformity. In other instances all the muscles are
paralysed quoad volition; but the greater mass and power of
the flexors and adductors, acting through the involuntary
contractility of the fibres, distort the limbs. Such patients,
affected with universal contracture, present deformity of
hips, knees, and ankles; the principal muscles that appear
contracted are the tensor vaginae femoris, rectus femoris,
the ham-string muscles, the gastrocnemii, and adductors, the

Paralytic contracture of right lower extremity. The left member totally and helplessly
paralytic without contracture. The case originally complete paraplegia. The more
favourable nutrition of the less affected side is conspicuous.

remaining muscles being wholly paralysed. The models
around you will illustrate the appearance of these patients;
they are compelled to effect locomotion entirely by the action
of the arms, using for this purpose crutches, or move from
place to place on a wheeled carriage, in the manner fre¬
quently displayed by mendicants in the streets of the metro¬
polis (fig. 51). As I have before mentioned, a single limb
or joint may be affected with paralytic contracture, and
sometimes one limb presents paralytic and the other spastic

PARALYTIC CONTRACTURES.

151

contracture, the deformity corresponding or not on the two
sides. Thus, therefore, nature presents us with two series
of deformities nearly identical in external appearance, and
your tact as practitioners in diagnosis and prognosis will
often be tested. You will at once comprehend that para¬
lytic contractures, on the whole, are the less favourable for
treatment. Still, immense advantages are secured to per¬
sons thus afflicted, if you can so restore the form of the
member that the patient may avail himself of a straight
pillar on which to support the trunk. When the muscles
on one side of the member only are paralysed, the adapta¬
tion of proper mechanical apparatus, with springs, in some
degree to supply the place of the deficient muscles, will
give the sufferer considerable tact and facility in locomotion.
Several cases of extremely severe paralytic contracture, the
individual never having walked, have, in this institution,
been enabled to throw aside crutches and the arm-propelled
carriages resorted to in the streets. When a single ankle

Fig. 52.

Paralytic contracture of both lower extremities. The knees acutely flexed, and the feet in
the position of T. equino-varus. The prognosis depends upon whether contracture or
paralysis preponderate. If the former, the prospect of restoration is greater.

152

PARALYTIC TALIPES EQUINUS.

and knee are affected, the patient may be restored to a
considerable extent, and perform the ordinary offices of
life with little inconvenience.

[Paralytic contracture in a single articulation is well illus¬
trated by the common non-
congenital Talipes equinus,
in which the heel is often
elevated to the highest ex¬
tent, the patient walking
upon the anterior extremi¬
ties of all the metatarsal
bones, as in fig. 53; the
deformity from a paralytic
origin often equalling the
severest spastic T. equinus.
Complete or partial para¬
lysis of anterior tibial mus¬
cles is the common cause of
this contracture, the exten¬
sor muscles of the toes be¬
ing either unaffected or hut
slightly involved in the pa¬
ralysis. When the paraly¬
sis is more severe, distinctly affecting the extensors of the
toes, these parts, instead of being extended, as in fig. 53, are
flexed towards the sole, as in fig. 55, the individual being
either precluded from using the limb or actually applying
the dorsum pedis, i.e. the upper surface of the tarsus and
metatarsus, to the ground (fig. 38). It is worthy of remark,
that in certain cases in which the respective characters of
paralysis and spasm are not well marked, a difficulty in
determining whether the case has primarily depended upon
paralysis or spasm may arise. In general, there is some¬
thing in the aspect of the case which, independently of its
history and of physical investigation, impresses the experi¬
enced eye with a certainty of its nature. Thus spastic

Fig. 53.

Non-congenital paralytic Talipes equinus.

PARALYTIC T. EQUINUS.

153

cases, besides the superiority in nutrition and tempera¬
ture, present often a bolder relief, whilst paralytic cases
are distinguishable by a characteristic softness of outline.]
Paralytic deformity of the upper extremity is more
serious; the member must be condemned to uselessness
so long as one set of muscles is unaffected by volition.
The movements of progression, performed by the lower
extremities, are more simple and considerable; use of these
parts is not incompatible with a certain amount of paraly¬
sis. A person can effect locomotion with a certain amount
of comfort and satisfaction even when the foot is completely
paralysed; but the functions of the hand are exceedingly

Fig. 54.

Fig. 54.— The sole of a foot affected with non-congenital T. equinus. The letters a he
indicate the situations covered with painful corns; o marks the position of the os
euboides, and d the under surface of the os calcis. The integuments investing these
two hones have never touched the earth. The letter e indicates a ridge occasioned by
the tense tendon of the flexor longus pollicis muscle and the internal edge of the thick
plantar fascia; m marks the external malleolus ; h the tense tendo Achillis.

Fig. 55.— Non-congenital paralytic Talipes equinus. Paralysis more considerable than in
fig. 54; h, heel extremely elevated; s, deep furrow in sole, resulting from attraction to
one another of all the plantar tissues, owing to the loss of their antagonists on the
dorsum pedis.

154

TREATMENT OF ARM-CONTRACTURE.

complicated: each muscular fibril has its appropriate action
Fig. 56. and subserviency to volition, and

requires to be balanced in its action
by its antagonist; when, therefore,
the supinators of the wrist, and ex¬
tensors of the wrist and fingers, are
paralysed, the functions of their an¬
tagonists are as completely arrested
as if all were afflicted with a com¬
mon calamity. This is, however,
the proper place to caution you not
too early to abandon a paralysed
hand and arm as incurable; it fre¬
quently happens that during the
continuance of the paralysis, con¬
traction and structural shortening
of one set of muscles (as in the leg
also) takes place, and on the removal
of the cause of paralysis resident in

Non-congenital paralytic T. varus. ' 1

The knee also paralysed, hut the nervous centre, the limb remains
with little contracture. contracted. In these cases you may

observe a germ of volition in the apparently paralysed
muscles, and by manipulation, friction, exercise, mechanical
support, and more rarely by electricity in its various forms,
you may succeed in partially restoring the limb. I have
witnessed cases of paralytic contraction of the arms and
hands consequent on fever, wholly restored after consider¬
able lapse of time by this treatment.

I shall conclude this lecture with a few remarks on the
utility of sections of numerous muscles of the hand and arm,
the substance of which has been elsewhere published by me.
Unfortunately, the universal tenotomists, who behold in a
contracted limb a mere piece of mechanism held in an ab¬
normal form by certain unnaturally tense cords, have, with¬
out reflection on the etiology and pathology of these defor-.
mities, proceeded with the knife to relax the contracted
part, regardless of the numerous conditions requisite for a

CENSURE OF INDISCRIMINATE TENOTOMY.

155

restoration of the function. In principle, subcutaneous
tenotomy is equally applicable to the upper and lower
extremities ; but a wide difference exists in the application
of the principle. The movements of the ankle consist, it is
true, of flexion, extension, adduction, and abduction ; but
in the act of walking, flexion and extension are alone ab¬
solutely necessary, adduction and abduction being only re¬
quired under extraordinary circumstances. Operative or¬
thopaedy is capable of restoring a contracted useless leg,
and fitting it for the ordinary purposes to which, in the
civilised state of society, it is applied, but cannot adapt it
to the extraordinary use made of it by the athletes or the
professional dancer. But in the case of the hand, every
individual, from the day-labourer to the watchmaker, or
the workman in the minutest branch of the arts, avails
himself constantly, not only of flexion and extension, but
of pronation and supination,—those movements which are
analogous to the inversion and eversion of the foot. If
you at the same time bear in mind that, notwithstanding
the analogy in these movements of the upper and lower
extremities, the acts of pronation and supination are far
more delicate and elaborate than the analogous movements
of the foot; if you remember that not only are the move¬
ments of the hand much more complicated, but that the
several fingers possess each their allotted muscles and con¬
sequent functions, you will at once perceive, that although,
in principle, orthopaedic operations are equally applicable
to the hands, the difficulty of applying the method must
be immeasurably greater. The anatomical conformation
of the arm and hand, the smaller space in which is accumu¬
lated a larger number of nerves, muscles, and tendons, the
difficulty of dividing those which may be contracted, with¬
out disturbing or exciting unnatural adhesions with those
which may be normal in their action,— all combine to re¬
tard the progress of orthopaedy in this direction. Opera¬
tions on the elbow are usually successful; in the hand also,

156

TENOTOMY IN ARM-CONTRACTURE.

when merely unnatural flexion or extension exists, paraly¬
sis being absent, the functions of the wrist may be re¬
stored by tenotomy. Thus, at the Orthopaedic Institution,

I have treated cases of contracted elbow and wrist which
have yielded perfectly, by section of the biceps or of the
flexors, extensors, and pronators of the wrist, the functions
having been more or less completely restored according to
the cause of the contraction. I may briefly state the order
of success in these cases to have been as follows: Organic
shortening of the muscles from long-continued relaxation,
as from accidental injuries and inflammation; congenital
contraction ; spasmodic contraction ; contracture from abs¬
cesses, with loss of substance, gangrene, &c. The result of
my observation leads me to assert, that how discouraging
soever at the outset, contractions of the hand are not irre¬
mediable ; on the contrary, that although few are perfectly
curable, the great majority are susceptible of considerable
benefit. Although the degree of restoration of function
varies, yet in nearly every case that has come under my
notice, the deformity (which alone frequently impels indi¬
viduals of the upper classes of society to seek relief,) has
been removed, and I have succeeded in enabling a person
to write tolerably well. A wide field, however, remains
open for future research and experience; and although I
would strenuously discountenance all rash and wholesale
division of tendons in these cases, I recommend the mat¬
ter to the attention of those who are possessed of an in¬
timate knowledge of the anatomy of the parts, and are
endowed with a large share of patience to watch and elabo¬
rate results. The loss of a lower extremity is a great priva¬
tion, but experience shews that the deprivation of the use
of the arm and hand is felt as a far greater affliction; so
much the greater, therefore, must be the reward of him who,
by adding to the common stock of knowledge on the remedy
of this infirmity, can so largely contribute to the welfare of
his fellow-creatures.

157

LECTURE X.

Paralytic deformities of the foot, continued—Talipes calcaneus—Mode
of origin and development of the deformity—Talipes calcaneo-valgus
— Treatment—Section ofperonei tendons—Value of removal of por¬
tion of tendo-Achillis and of cutis, to effect artificial contraction —
Artificial talipes calcaneus in Chinese women—Paralytic talipes val¬
gus ; paralytic talipes varus—Table of these deformities. [ Contractures
from abscess, from sloughs — Contracture of lower jaw—Peripheral ?
—Spasm and peripheral paralysis'].

Hitherto, among the spastic and paralytic contractures
of the ankle, I have not fully described an uncommon
kind of deformity, talipes calcaneus (fig. 57), in which,
through preponderating action of the anterior tibial muscle,
the front part of the foot is elevated, the heel receiving
the weight of the body. A similar deformity has resulted
from the cicatrix of a burn on the front of the ankle, and

Talipes calcaneus in a child aged four years and a half.

158

TALIPES CALCANEUS.

consequent contraction of the cutis and subjacent tissues,
by which constant abnormal bending of the foot has been
produced.

You should not, however, imagine that the toes are
always so completely elevated as in the model; in standing

Fig. 58.

PROGRESS OF T. CALCANEUS.

159

This deformity, in its advanced grade, becomes modi¬
fied, so that you might with difficulty recognise it in this
series of models (figs. 58 and 59). When the most de¬
formed of this series was first presented to my notice in
1836, I was much embarrassed to determine its nature, its
precise pathological character.

I regard this series of talipes calcaneus as worthy of
attentive study, because it satisfactorily illustrates the man¬
ner in which secondary changes ensue on disturbance of
the equilibrium in different sets of muscles. The essence
of the disease consists in debility or paralysis of the gas-
trocnemii, and proportionate preponderating action of the
anterior muscles of the leg. In walking, the individual
possesses no power of elevating the heel, but may, by
volition, permit the front of the foot to drop; besides
which, the weight of the body propagated from the leg
to the tarsus tends to depress the toes. The debility of
the gastrocnemii may exist for a considerable time, until
the commencement of deformity and increase of lameness
excite apprehension. You will perceive that in the smallest
model, from a patient aged six years (No. 5), the effect
of treading exclusively on the heel is already manifested
by considerable increase in size of the part; whilst the
want of power in the gastrocnemii to balance the con¬
tractility of the muscular tissues of the sole is the mutual
approximation of the tuberosity of the os calcis and the
anterior extremity of the metatarsus, causing an augmen¬
tation of the concavity of the sole. The front part of the
foot being inactive is arrested in its development and dis¬
proportionately small. The remaining models illustrate
the increase of deformity with advancing age. No. 2 re¬
presents the foot of a young lady setat. fourteen, and No. 1
that of a gentleman aetat. sixteen; the deformity has here
attained its highest grade.

In both of these models you may study the -operation
of other muscles, which, although they may not have lost

160

T. CALCANEO-VALGUS.

their antagonists, increase the deformity by the alteration
of their modes of action. The power of raising the heel
is lost, but the peroneus longus, besides being an abductor
of the foot, presses the great toe to the ground, and draws
it back towards the origin of the muscle; its fibres then
become structurally shorter, and by their continued tension
occasion the deep cleft visible on the outer margin of the
foot, where the tendon passes around the os cuboides pre¬
viously to entering the sole. The augmentation of the
convexity of the dorsum and hollowness of the sole reaches
the maximum in these models.

In No. 3, figs. 58 and 59, the deformity, owing to par¬
ticipation of the anterior tibial muscle in the paralysis, is
varied by the outer edge of the foot being entirely raised,

Fig. 60.

T. calcaneo-valgus seen from the outer side, c, outer side of heel, slightly raised from
the ground in act of walking; d, middle portion of outer margin of foot, much raised
from the ground, so that the light, as at e, may be seen beneath the sole;*/, hollow
resulting from the astragalus having lapsed towards the inner side of the foot. The
tense peronei tendons are visibly prominent behind malleolus.

* In this respect an exaggerated condition of that form of foot regarded
as perfection. The eccentric Lady Hester Stanhope boasted that a mouse
could run under her sole without touching it.

t. calcaneus: medicinal treatment. 161

the peronei here being imperfectly balanced. To this
form of the affection, through the peronei greatly everting
the toes in walking, I apply the term Talipes calcaneo-
valgus (see also fig. 39, p. 124, and fig. 60).

Now, the practical value of these remarks on the origin
and progress of this deformity is, that it teaches us the
importance of endeavouring early to arrest its course by
attending to the primary paralysis. You will probably be
surprised to know, that in every one of the patients from
whom these models have been taken the disease was during
infancy overlooked; and it is only by a comparison of these
cases with those of still younger subjects affected with the
paralysis and the incipient deformity, that I am enabled
to describe to you its nature.*

The “ weakness” of the limb in each of these five pa¬
tients was observed by the anxious parents, the best sur¬
gical aid was sought, and the subjects pronounced to have
nothing the matter with them. In other cases the opinion
given has been, that on completion of dentition the weak¬
ness would disappear. If hopes be raised on this expec¬
tation, you will, in the majority of instances, be disap¬
pointed. You should attentively ascertain whether any
internal organ be injured, and maintain a disordered condi¬
tion of the brain and spinal cord, exciting paralysis of one set
of muscles, or abnormally increased activity of others. Ac¬
cording^ to the nature of the case and constitution of the
patients, test the value of purgatives, counter-irritation to
the head or spine, iron, iodine, or liquor potassse arsenitis,
frictions and manipulations to the limbs, and the use
of a boot and iron calculated to prevent bending of the
foot, with a high heel to favour retraction of the gastro¬
cnemius, or prevent its being reduced to a riband by the
action of the anterior muscles of the leg. If the deformity
should have reached the highest grade, it constitutes an
almost intractable case. Section of the peronei tendons
* See West on Diseases of Infancy and Childhood, 1848.

CALCANEO-VALGUS : OBJECTIONS TO

and of the contracted plantar tissues may then afford some
benefit as regards the deformity, if the treatment he fol¬
lowed by appropriate attempts to flatten the foot. In
Talipes calcaneo-valgus the above section is still more ser¬
viceable, by causing the individual subsequently to walk on
the outer edge of the foot as well as on the heel and great
toe. This adds greatly to the patient’s comfort, as before
the section the inner ankle is continually prone to he pro¬
jected inwardly, with the sensation of impending disloca¬
tion of the tarsus. It has been recommended, that as the
tendo-Achillis in this deformity appears too long, you
should remove a portion of it, and thus seek to produce
contraction, or, more properly, shortening of the gastro-
cnemii. Now, if the description of the nature of the pri-

Figs. 61 and 62. T. calcaneo-valgus before

ABLATION OF PORTION OF TENDO-ACHILLIS. 163

mary lesion which I have given you be correct, benefit
will not he anticipated from that proceeding; indeed, you
will regard it as a worthless project, one not founded on
pathological notions, hut simply on mechanical ideas, on
the mere regarding one tissue as too long, another as too
short. I may take this opportunity of assuring you, that
you can never treat a deformity with advantage to the pa¬
tient or to your own satisfaction and reputation, unless
you thoroughly understand the pathology of the case. De¬
formities have too long been treated as they have been
regarded—as mechanical affections. I have, in former lec¬
tures, said enough to demonstrate that they constitute one
of the most interesting branches of pathology. With re¬
spect to this operation of removing a portion of the tendo-
Achillis, I ought to inform you that I have twice performed
it, with some modification, on the principle that, if incapable
of aggravating the patient’s condition, a certain amount of
physical contraction above the heel might possibly benefit
the patient. We daily witness the effect of contraction of
the skin, after burns and sloughs, in abnormally contracting
various parts. It occurred to me that, if, together with re¬
moval of a portion of the tendo-Achillis, a portion of the
loose skin above the os calcis were removed, such an amount
of contraction might be artificially induced, as would, in
some degree, counteract the contraction of the plantar tis¬
sues, and prevent the os calcis from being drawn from its
naturally almost horizontal position into one nearly vertical.
I twice performed this operation with so little benefit that
I do not recommend its repetition.* (See description of
figs. 63, 64.)

* The above observations on the inutility of the removal of portion of the
tendo-Achillis constitute the whole that the author has ever said or written
on the subject. He was much surprised to read in one of a series of papers
on the pathology of deformities, contained in the Lancet four or five years
ago, by a surgeon of peculiar pretensions, that “Dr. Little recommends
that when a muscle is too long, a portion of it should be cut out; and that

164

calcaneus: mechanical treatment.

I may describe the treatment that I have found ad¬
vantageous under two heads; that applicable to the earliest
stage, before great contraction results, and that necessary
when the deformity is considerable. It is unnecessary to
repeat here the general means of endeavouring to remove
paralysis or prevent contraction. Those specially applica¬
ble to Talipes calcaneus consist of a mechanical instrument,
or iron, so arranged at the ankle-joint as to prevent bend¬
ing of the foot beyond a right angle. If the instrument-
maker possesses sufficient ingenuity and skill to accomplish
this by a spring (p. 35), the object of assisting the weak
gastrocnemii and controlling the over-acting anterior mus¬
cles of the ankle will be realised. The patient should
wear a contrivance at night for a similar purpose (figs. 65
and 66).

[For many years the author has been accustomed to
employ this apparatus, contrived by him for prevention of
the deformity, when the initiatory paralysis is discovered,
and for restoration of such cases, whether- or no surgical

■when it is too short, it should be cut through.” The author, considering the
source of this mis-statement of his opinions, did not believe it consistent
with the position he desires to hold in the estimation of his medical brethren
to notice it. The same attempt to discredit tenotomy in the practise of its
known promulgator is repeated, ipsissimis verbis, in a treatise “ On the Pa¬
thology of Deformities''' recently published. If a person profess to write on
the pathology of deformities, and criticise, or pretend to quote an author’s
views, it may reasonably be expected that he should have previously made
himself acquainted with those views, and have had some experience in the
matter in question. The extraordinary errors into which the writer in ques¬
tion has fallen proves that he possesses neither of these qualifications for a
critic on the writings and practice of others.

The Lectures here reprinted after the lapse of nearly ten years demonstrate
the author’s anxiety to reduce the application of tenotomy as a rule to cases
in which structural or organic shortening of tissue has taken place, and which
oppose approved mechanical treatment. Respecting removal of a part of a
tendon, the text shews that, although the author considered the operation as
one not unworthy of trial, he discountenanced its application on the ground
that equal benefit could be obtained without it.

CALCANEO-YALGUS : TREATMENT.

165

operation has been performed as a preliminary proceeding.-
It is scarcely necessary to observe, that it is intended to be

Figs. 65. and 66.

worn at night only, or during repose, whilst at study for
example, or during any sedentary occupation. He has never
tried reversing its application to the dorsum of the foot,
which would be practicable; nor the addition of thick heel
and toe pieces, so as to permit its use during locomotion.
Latterly he has used the ratchet movement a substituted
for male and female screw.]

A raised heel is often serviceable by more completely
throwing the weight of the body on the tarsal arch; for
unless attention be given to this circumstance, partial dis¬
placement of the tibia and fibula backward ensues. If, in
the progress of the deformity, the toes incline outwardly,
as in valgus, constituting Talipes calcaneo-valgus, the pe-
ronei may become structurally shorter, and the foot not
replaceable beneath the axis of the leg without mechanical
elongation of the peronei, or even section of them. When,
however, the deformity is severe, palliation is the utmost
that can be effected. In such cases a spring, with con¬
vexity towards the inside of the leg, or an “iron” upon
the outside, should be worn.

[The author has met with some rare cases of lameness
and deformity, which, besides their inherent interest, are
valuable in throwing light upon the pathology of calca-

166 CALCANEUS FROM RUPTURED T. ACHILLIS, ETC.

ileus.* Thus he has seen this deformity produced by pe¬
ripheral paralysis of gastrocnemii after over-exertion,f by
accidental rupture of tendo-Achillis,J and by imperfect
reunion after surgical division of it.§]

* The prefix * Talipes’ will often, for the sake of brevity, be dropped in the
succeeding pages.

f A gentleman aged 32, by temperament predisposed to disorder of nervous
system, much addicted to field-sports, observed, after a long walk over ploughed
ground, weakness of the left leg, at first attributed to sprain or over-exertion.
The accompanying lameness did not subside. Gradually be perceived an in¬
ability to hop or spring with the affected member, and he suffered pains in
the ankle similar to those which result from excessive standing. A few months
after the occurrence of the lameness he consulted the author. On examina¬
tion, partial wasting and flabbiness, with imperfect volition in the muscles of
the calf, were observed. The heel was already larger than the opposite, and
complaint was made of uneasy sensations in it, as if produced by undue
pressure; the sole was beginning to contract, and the peronei to manifest
an undue influence in the movements of the foot. Diagnosis: Peripheral
partial paralysis of gastrocnemii from excessive exertion, relaxation of tendo-
Achillis, weight of body inordinately borne by the heel, development of cal¬
caneus, and probably ultimate calcaneo-valgus from preponderating action of
anterior and external muscles of the ankle.

J A stout gentleman about 40 years of age ruptured the tendo-A chillis in
jumping from a considerable height upon the deck of a ship. The resulting
injury and lameness were attributed to sprain, and rest for a few days was en¬
joined. Lameness, however, continued, accompanied with gradual wasting of
the calf. A few months afterwards the author was consulted. The patient
walked with much lameness, and was soon fatigued; the gait was particularly
deficient in elasticity. The foot, on examination, had already acquired distinct
traces of calcaneus. The posterior part of the foot (calx) was abnormally large,
the tendons on front of ankle unnaturally tense; the anterior part of the sole
exhibited, in the comparative softness of the integuments, a want of evidence
of use ; the calf was short and attenuated, and the tendo-Achillis united by a
slender ligamentous band. It is scarcely necessary to observe, that calcaneus
in a person aged 40 would never reach the grade attained in children, in whom
the deformity progresses during the growing period of the frame. The simple
surgical proceedings described in the following case would have entirely re¬
stored the patient. The gentleman in question being compelled to return to
Australia, could not devote the time requisite for owe.

§ A third case of incipient calcaneo-valgus, induced by an uncommon
cause, was observed by the author in 1841, in consultation with Mr. Jackson,
Spitalfields.

A young girl affected with slight angular knee-contracture and contracture

OPERATION FOR, REUNION OF TENDON.

167

I cannot quit the subject of Talipes calcaneus without
directing attention to a deformity of this nature artificially
produced among the Chinese. Here is an anatomical draw-

of ankle (equinus), after inflammation and suppuration in the leg, underwent
section of T. Achillis and peroneL Either through constitutional debility or
coldness of the weather, the ordinary effusion of uniting medium did not take
place. Six weeks afterwards, notwithstanding the heel had been carefully
kept elevated, the foot was flexible and straight; she could walk without
pain, but with some lameness. The fears of imperfect reunion of tendo-
Achillis which had been entertained were justified by the result; for it was at
this period observed that she trod exclusively on the heel, and that the anterior
muscles of the ankle elevated the front part of the foot from the ground.
Traces of calcaneo-valgus were already observed in the form of the heel and
sole. The divided extremities of the tendo-Achillis, still somewhat swollen,
were seen and felt nearly two inches asunder; they appeared to be connected
by a thin strip of ligamentous or other band, probably only the thickened fascia.

At the eighth week the author devised and executed the following opera¬
tive proceeding for effecting reunion of tendo-Achillis:

The patient was placed in the prone position. Holding an ordinary narrow sharp-
pointed tenotomy knife in a position transverse to the limb, the operator introduced it
through the integuments on the outer side of the ordinary course of the tendo-Achillis,
near the spot where the section of the tendon had at the outset been effected. After tra¬
versing the integuments, he shifted the direction of the tenotome, directing it parallel
to the limb, carrying the point of the knife upwards towards the superior end of the
tendo-Achillis, and with it lacerating any adhesions the tendon might have contracted
in that situation, as well as the face of the severed end, so as to insure exudation of blood
and plastic matters from its surface; the point was then swept downwards, along the
interval left by the retracted upper end of the tendon towards the cut surface of the lower
portion of the tendon: this was similarly lacerated, and the knife withdrawn. A punc¬
ture in the integuments remained, through which a few drops Of blood issued. The pre¬
vious gap between the ends of the tendons was now occupied by a considerable san¬
guineous effusion.

The steps of this operation, thus fully detailed, occupied but a few seconds, and
caused but trifling pain, compared with the important probable result of reunion of the
tendo-Achillis. The knee, leg, and foot were again carefully, but not tightly, bandaged
in the extended position, so as to approximate as nearly as possible the severed ends of
the tendon, and to keep the knee and ankle joints in repose. Neither inflammation nor
pain followed. At the expiration of a fortnight the splint and bandage were removed.
Abundant effusion of plastic material and adhesion of tendon had taken place. Very
cautious bending of the ankle was now effected.' In ten days it was reported that the
foot was flexed to an angle of 45°. At the expiration of a month permission was given
to recommence gentle exercise, using a laced boot supported by an iron stem. At the
end of the sixth week the report states: “ Union of tendo-Achillis perfect, the foot is
perfectly flexed, the knee straight and flexible, she walks in a common boot.”

The author occasionally saw this patient afterwards. No trace of Talipes equinus, or
of Talipes calcaneo-valgus, remained; indeed, restoration was complete.

Jan. 18, 1845. The tendo-Achillis somewhat longer than natural; slightly thickened
at the operated part; no adhesions to integuments; right surales short; difference between
bulk of the muscles of the calf on both sides inconsiderable; walks perfectly free from
lameness.

Remarks from Provincial Medical and Surgical Journal, May 1851.—“The author is

168

ARTIFICIAL T. CALCANEUS.

ing of the hones of the foot of a Chinese lady, obtained
during the late China
expedition (fig. 67).

I possess no anato¬
mical drawing of the
dissection of a Ta¬
lipes calcaneus pro¬
duced naturally in
the manner previous¬
ly described, as I have
had no opportunity
of dissecting this de¬
formity after death;
but you can compare
the drawing of the dis¬
sected Chinese lady’s

induced to give publicity to this case less as an instance of successful cure with the aid
of tenotomy, than to point out the manner in which an accidental failure of union of a
severed or ruptured tendo-Achillis might be repaired. The instance related shews that
non-union of a severed or ruptured tendo-Achillis, although a rare occurrence, is not a
mere hypothetical case.

“The causes of non-union in the child appeared to be diminished effusion of plastic
matter immediately after section of the tendo-Achillis, the consequence of languor of
circulation, or of some inherent vice of constitution, aggravated by the too-sudden
elongation of the space between the severed ends of the tendon, either by the me¬
chanical instrument used, or by the injudiciously early walking exercise. The slowness
with which wounds cicatrise in a cold climate is well known, and the author has witnessed
a puncture resulting from subcutaneous tenotomy bleed like a fresh puncture ten days
after operation during the rigours of a severe Berlin winter; and frequently in cold
weather in our own country he has found it necessary, after subcutaneous tenotomy, to
envelope a feeble limb with cotton and flannel in order to accelerate union. The influ¬
ence of too-eonsiderable and too-early separation of the ends of a severed tendon, and
especially of frequent motion, as in walking, in interfering with union, is incontestable.
The reparative powers of the system, however, usually suffice to neutralise any injury
from too-great or too-hasty separation. Experiments upon animals have proved that
considerable lengths of tendon may be excised, and union nevertheless ensue; but the
knowledge possessed of the great extent of the powers of the economy and of a part,
is an insufficient reason for neglect of those rules and acts of caution which experience
dictates. The immediate separation of a severed tendon to too great an extent should be
avoided. Half or three quarters of an inch may be safely borne, although as a rule
gradual separation is preferable. The condition of a severed tendon approaches that of
a fractured bone; too-great separation of the severed ends, depression of temperature
sufficient to suspend active arterial circulation, too-early movement of the parts, and
inherent vice of constitution, will cause tendon and bone to remain ununited, to the
great detriment of the sufferer.” Stromeyer relates from Edin. Med. and Surg. Journal,
Oct. 1836, that Mr. Syme reunited a divided tendo-Achillis by cutting down upon it and
bringing the ends together by suture. Risk of suppuration great in this proceeding 1

Fig. 67.

Artificial skeleton of a Chinese Lady’s foot. “ Arti¬
ficial T. calcaneus." I am indebted for this draw¬
ing to Mr. Goldsmith, Islington.

T. EQUINO-VALGUS.

169

foot with the model of the highest grade of Talipes cal¬
caneus, and you will perceive the similarity, if not the
exact identity, in the conformation of the bony struc¬
tures in the two cases, except as regards the smaller toes.
The artificial deformity is effected by tightly bandaging
the foot in early life, and folding the smaller toes be¬
neath the sole. This evidently renders locomotion on
the sole painful; the individual is constrained to walk
exclusively on the heel; the anterior muscles of the leg
acquire a preponderance, and elevate the dorsum of the
foot; the muscles and ligaments of the sole increase the
convexity of the dorsum and consequent concavity of the
planta ; and the gastrocnemii probably become in time
atrophied and powerless, rendering the analogy with the
natural Talipes calcaneus complete.. The artificial will
offer a far greater chance of cure than the natural deformity,
as in the artificial absolute paralysis of gastrocnemii does
not exist. I do not entertain the slightest doubt that it
may be entirely cured, even after thirty or forty years’
duration, by means similar to those employed in its pro¬

duction, viz. appropriate bandag¬
ing; and should any muscles have
become structurally shorter and in¬
superably oppose elongation, teno¬
tomy might be employed. The assi¬
duous labour of years wilfully, oc¬
cupied in distorting nature might
be undone in a few weeks.

[The form of paralytic or spas¬
tic Talipes equino-valgus (elevation
of heel with eversion of toes) is well
illustrated by the fig. 68. The ex¬
ample is taken from a child before

T. equino-valgus. Contraction of
gastrocnemii and peronei from
paralysis of anterior tibial.

secondary deformity from standing or walking has been
produced. The objects to be attained in the treatment

consist, 1st, of remedies directed to removal of the spasm
or of the paralysis ; 2d, of those calculated to prevent struc-

170

paralytic valgus.

tural shortening of the contracted muscles; and 3d, mecha¬
nical support to prevent secondary deformity from use of
the member.]

Here is a model
(fig. 69) which will
illustrate the na¬
ture of paralytic
Talipes valgus, and
here another (fig.
70) illustrative of
paralytic varus.

[Reflection on
the extreme defor¬
mity presented in
fig. 69 has led me
to the conclusion that it was originally more similar in form
to the case of T. equino-valgus, fig. 68, and that it has attained

Talipes valgus paralyticus.

Fig. 70.

Talipes varus paralyticus (i interior aspect).

the present state through aggravation by use of the limb.
It will he obvious that if the subject of fig. 68 were left to
nature, the act of treading on the inner margin; of the
great toe would tend more and more to evert the foot, and
the entire inner margin in time touch the ground; but as

PARALYTIC VARUS.

171

in T. equino-valgus the gastrocnemii are tense and con¬
tracted, the tendo-Achillis would resist depression of the
heel, consequently the foot would bend in its middle, the
heel being slightly elevated, contrary to the disposition of
the same part in T. calcaneo-valgus. The fig. 69 there¬
fore, although designated T. valgus, is in reality T. equino-
valgus, in which secondary deformity has taken place.]

I have sufficiently described the general treatment of
these deformities; a few special considerations only need
detain us. In both, after restoration of form, a properly
constructed shoe, to hold the foot in a straight position,
and to facilitate locomotion, may be required; when much
structural shortening exists in valgus, section of the peronei
may be indispensable; and in (paralytic) varus, division
of the posterior tibial, tendo-Achillis, and plantar tissues,
may be required. (See Operations, p. 92.)

Fig. 71.

T.varus paralyticus (posterior aspect). Treatment: Section of T. Achillis and mechanical
extension of remaining contracted structures. The reader desirous of possessing the
minute details of history and treatment will find them, Case XXII., appended to first
edition of Treatise on Club-foot, %c.

[The instruments best adapted for the mechanical treat-

172

CONTRACTURE FROM CICATRICES

ment of several contractures will be found under tbe treat¬
ment of “ Congenital distortions.”]

Tbe following diagram of contractures of tbe ankle is
intended to shew tbe manner in wbicb tbe compound forms
are derived from simple ones.

Simple Forms.

1. Talipes equinus.

2. Talipes valgus.

3. Talipes varus.

4. Talipes calcaneus.

Compound Forms.

5. Talipes equino-valgus.

6. Talipes equino-varus.

7. Talipes calcaneo-valgus.

[8. (?) Talipes calcaneo-varus.]

Each may be either spastic or paralytic.*

[Tbe following distortion will illustrate contracture
arising from combined causes: — habitual retention of
members in one position,
with contraction of cica¬
trices. Fig. 72 represents
tbe knee and foot of a child
who suffered from extensive
phlegmonous erysipelas at
tbe early age of five months.
Profuse deep-seated suppu¬
ration extending from hip to
foot, pointing in numerous
situations, ensued, tbe limb
having been literally riddled
with openings. The deep
seams, bridles, and inequali¬
ties, formed by dense fibro-cutaneous cicatrices, yet visible,
suggest tbe extent to wbicb the various muscular, fascial,
and tegumentary structures became permanently aggluti¬
nated. Tbe knee, although capable of further flexion,
was incapable of extension beyond the position shewn in

* The author has added to these forms the query whether a T. calcaneo-
varus from spasm or paralysis exists. He has seen no such contracture,
although a congenital distortion which might be so named does exist.

Fig. 72.

contraction of cicatrices after phlegmonous
erysipelas.

AFTER SUPPURATION.

173

tlie figure ; the ankle, although not immovable, permitted
no range either of flexion or extension. The leg was out¬
wardly rotated, partaking much of the character of genu-
valgum (see Rachitic Deformities), the patella presenting
upon the external condyle. On
endeavouring to extend the knee
and foot, the tension of the im¬
mense cicatrix on the outside of
the knee and thigh, with the sub¬
jacent biceps tendon, and of a ci¬
catrix on front of ankle, which
involved the anterior muscles of
ankle, was much augmented. The
fig. 73 indicates the extent to
which restoration, with the aid of
section of biceps femoris and pa¬
tient mechanical extension, was
effected.*

* The child, when placed under treatment, had attained the age of five,
never having walked. Tenotomy was performed, May 1851, with the efficient
assistance of Dr. Freeman of Edgebaston (a gentleman whose early retire¬
ment from the practice of his profession is a loss to science). In order to pre¬
vent disturbance of the limb, interference with healing of the puncture, and
possible setting-up of a point of suppuration in the ham, the limb was care¬
fully maintained at rest, for a few days, upon a common bent knee-splint. It
may here be observed, that this precaution was taken rather in deference to a
somewhat antiquated pathology, which regards cicatrix as more susceptible of
injury, than from the belief of its absolute necessity; for the author’s expe¬
rience shews, that after a cicatrix or new tissue has become somewhat old, it
more fully partakes of the vitality of surrounding parts, and may be freely
dealt with by the surgeon. On the sixth day a common knee-extending appa¬
ratus, consisting of two metal splints connected by a hinge opposite the ham,
regulated by a ratchet-screw (p. 80), with an ordinary foot-piece as in Club¬
foot (see Congenital Distortions), was applied. The mass of resisting struc¬
tures rendered slow progress unavoidable; at the expiration of six weeks the
knee was extended, but inversion of knee (Genu valgum) more considerable.
The apparatus was now modified by placing the adjusting screw on outside of
limb, instead of opposite the ham; by which means, in the course of an addi¬
tional six weeks, the inversion of knee was overcome, and the knee in the

174

CONTRACTURE FROM

Another remarkable contracture from preponderance
of one set of muscles and ha¬
bitual retention in one position,
is afforded by the subject of
fig. 74,* which represents the
case of a young lady, aet. 15,
who seven years before laboured
under severe typhus fever, dur¬
ing which extensive sloughs pos¬
teriorly, involving nearly the
whole of the sacrum and nates,
and laterally exposing both tro¬
chanters, occurred.

Probably through weakening
of glutsei muscles, the adductors
of the thighs habitually drew
the limbs inwardly ; and ultim¬
ately their contraction being unresisted by volition, crossed

position seen fig. 73. The foot in the meanwhile favourably progressed with¬
out operation. The child now made his first attempts at walking, flexion of
knee to the extent of a few degrees was acquired, and in five months from the
date of tenotomy walked very well. He was dismissed from treatment with
the injunction to the friends not to sacrifice the straight position of the limb
during attempts to acquire more mobility of the joint. In all cases of knee-
deformity, in which the patella has permanently quitted the trochlea of the
condyles, it is undesirable to attempt the acquisition of much mobility; for
the want of a proper fulcrum on which the extensor muscles can act, renders
mobility of knee-joint a source of weakness rather than of strength. In many
cases considerable improvement in position of patella is obtained during the
mechanical strengthening of the knee. This replacement is prevented when
the patella is drawn from its place, as in the present case, by dense fibro-cuta-
neous cicatrices. The cicatrix which thus abnormally holds the patella is shewn
in fig. 73. I have since heard from Dr. Freeman that the case has done well.

* The right foot presented in the situation of the left, and vice versd.
Excepting the awkward appearance of the feet thus reversed, no deformity
was apparent in the sitting posture. The diagnosis and prognosis were ob¬
scure, in consequence of the immobility of thighs having prevented examination
of condition of hip-joints ; but, notwithstanding the apparent improbability of
restoration of position, replacement was attempted solely by mechanical means.

Fig. 74.

HABITUAL RETENTION IN ONE POSITION, 175

the limbs over each other, in which uncommon position
they were rigidly fixed at the period of the author’s first
examination. The case* is, moreover, extraordinary, by
indicating the enormous loss of parts by sloughing after
typhus, from which a young person may recover by judicious
and persevering attention on the part of the surgeon.f

Manipulations (p. 26), calculated to separate the thighs ; then the interposition
of pads between the limbs, and afterwards a male and female screw, adjusted so as
to press against the internal j 5

condyles, constituted the
means used (see fig. 75).

After four months’ continu¬
ance of this treatment the
limbs could voluntarily be
held asunder, and gradually
locomotion was attempted.

At the expiration of 'other
two months, locomotion
with crutches was exchanged
for the use of sticks ; and al¬
though from the hollowness
of lumbar region and limited
movement of hip-joints, it
became evident that the sus- TMs s ; mple ap p ara tus, devised by the author, has been
picions respecting the hip- published without acknowledgment by a surgeon
joints (extra-articular impli- who is indebted to the author for a knowledge of its

cation) were justified, the use ‘

beneficial change in the patient’s condition was matter of surprise to all her
friends. She had not walked since the original illness.

* The author has to thank Mr. Adams of Lymington, Hants, for the
history of this interesting case.

f Whilst alluding to the subject of sloughs during or after continued fever,
the author may be permitted to mention a severe case which came under his
notice in consultation with Mr. Arthur of Shadwell, and which exemplifies
the value of the prone position in some states of disease:

A boy, set. eleven, at sixth week of continued fever, presented an enormous slough,
upwards of nine inches in diameter, exposing bones and muscles of sacrum andnates. The
knees were pertinaciously flexed, and approached to the abdomen. Any movement of
limbs or trunk called forth agonising cries. Abandonment of the copiously suppurat¬
ing surface enveloped in soothing cataplasms, exposed to some pressure in the supine
position, even upon a water-bed, appeared unavoidable; whilst recovery from so great
destruction of parts in the enfeebled typhus convalescent seemed improbable. It was re¬
garded as a lost case. Trial of a prone position was for the following reasons indicated:
1st. Extension of the thighs rather than flexion would be favoured by it, and thus a

176

CONTRACTURE OF MAXILLAE.

Many cases popularly termed locked-jaw, sometimes
accompanied with cicatrices in the mouth, consequent upon
the ulceration which occurs after fevers, ptyalism, stoma¬
titis, or cancrum oris, present themselves, in which, after
patient trial of mechanical means, and a satisfactory diag¬
nosis of absence of true ankylosis of the maxillary articu¬
lations, myotomy and division of cicatrised bands, if any
such he present, would lead to relief of the contracture.
The author has successfully employed division of masse-
ters in a case the particulars of which have been al¬
ready published (see the Lancet , Sept. 6, 1851; see also
Appendix).^ If the teeth can be separated to the extent of
a line or more, boxwood wedges, mg. n.
or a piece of bone or ivory,
wedge-shaped at the extremity,
and provided with a handle long
enough to be used as a lever,
or the instrument, fig. 76, may
be employed for mechanical se¬
paration of the maxillae. These
means have the disadvantage of
exercising pressure upon two
opposing teeth only. If the
mouth can be more widely
opened, the apparatus, fig. 77, will better adapt itself to the
incisor teeth. Cases, however, occur, in which, in conse-

lessening of the size of the suppurating surface he immediately eifected. 2d. All pres¬
sure upon the wounds, and movement of the sutferer during necessary applications to
them, would he avoided. 3. This position, whilst remedying the approximation of the
thighs to the abdomen, would favour straightening of the knees, as these parts could
scarcely continue long flexed in the prone position of the trunk. A rude couch was pre¬
pared in accordance with these indications, consisting of an ordinary double inclined
a plane reversed, of which the annexed diagram repre-

sents the section: a, section of surface upon which the
^ head, chest, and abdomen reposed; b, section of piece
connected by hinges to a, adapted to thighs; c, section of piece similarly fixed by hinges
to b, adjusted to legs. The patient at once obtained relief and sound sleep upon this
couch; he partook heartily of animal food and good malt liquor. The pieces c and b were
gradually brought into a line with a, and in a few weeks the sores were entirely healed,
and the patient restored to health and activity.

MECHANICAL SEPARATION.

177

quence of the mouth being so firmly closed that the edges
of the lower incisors are on a higher plane than Fig 78 ,
those of the upper teeth (within and behind the
upper teeth), none of these contrivances can be
introduced. Under these adverse circumstances,
an ingenious combination of the wedge and screw
(fig. 78), devised by my friend and colleague,

Mr. Barrett of Finsbury Square, is invaluable.

The centre part may be constructed thin enough
to pass through the smallest separation of the
teeth, and may be bent so as to be looped over
the concealed lower incisors. It possesses the
additional advantage, that when thus introduced
into the mouth, after passing between the upper
and lower incisors, it can readily be pushed be¬
tween the molars, and the force be applied upon
that part of the dental arch (the molar) which
bears pressure with the least inconvenience or
suffering. The apparatus may, moreover, be
made to. act upon one ramus or upon both rami
of the maxilla at the same time. The author has
derived great advantage from anaesthesia to the
first degree in a difficult case, by its having facili¬
tated introduction of the instrument. In con¬
sultation with Mr. Barrett, and another friend
and colleague at the London Hospital, Dr. Parker,
full separation of maxillae which had been immov¬
ably closed fourteen years, in consequence of sup¬
puration in both parotid regions after scarlatina
in childhood, was accomplished.]

* Mr. Barretts instrument for opening mouth closed from muscular or other contraction.
a, metallic oblong frame constructed of German silver (a metallic compound believed
by Mr. Barrett not to excite, when introduced into the mouth, the involuntary con¬
tractility observed during the use of a similar instrument of steel); b b, ivory wedges,
destined to be propelled onwards by the action of the screws c c ; d d, metallic pins or
rivets firmly connecting the lower piece of metal frame to the end pieces. The upper
piece of metal frame is only loosely secured by these pins, in order that thicker wedges,
when required during the progress of the case, may be introduced into the frame. The
edges of upper and lower pieces of the frame may be turned towards the opposite
piece, by which means a channel is formed, along which the wedges can be propelled
without their thin ends quitting the frame.

178

LECTURE XI.

Contracted hand and fingers from disease of palmar fascia — Proba¬
bility of origin from gastro-intestinal disturbance and rheumatic dia¬
thesis — [Neck deformity from syphilis]—Spasmodic contracture of
fingers and hand — [ Writer’s cramp and paralysis'] — Treatment —
Non-congenital wry-nech from spastic contraction, paralysis, rheuma¬
tism, voluntary retention [from diseased lymphatic glands ]— Treat¬
ment — Utility of section of sterno-cleido-mastoideus —[ Contractures
from cicatrices of burns — Mechanical extension — Section of con¬
tracted bands.]

When one or more of the articulations of a finger become
contracted from disease of the articulations, often com¬
plicated with thecal abscess, the case constitutes false an¬
kylosis of the affected articulation, the treatment of which
has been already described. I may here remark, that such
deformities of the finger do not admit of restoration; or if
the bent condition he removed by tenotomy, the function
4s not always restored, either in consequence of the tendons
having sloughed, or from their having become adherent
to the sheath during the primary disease, or from the ar¬
ticular surfaces having received irreparable injury. But
in contracture of the fingers the abnormal flexion has re¬
sulted from causes which have operated indirectly on the
articulations. These causes may he superficial inflamma¬
tion of the hand and fingers, chronic disease or injury of
the palmar fascia, superficial wounds of the finger, injury
to the flexor tendons, rheumatic inflammation (p. 100), and
lastly, disease in the nervous system, in which case the con¬
tracted finger ranks as a spasmodic or paralytic contracture.

One of the most interesting and common forms of con¬
tracted finger is that resulting from disease of the palmar
fascia, as at p. 105. In this affection the middle, ring, and
little fingers are principally liable to contracture. I do not

CONTRACTED PALMAR FASCIA.

179

remember to have witnessed contracture of the forefinger
from this cause.* This probably depends on the anatomical
distribution of the fascia. The contracture [usually] com¬
mences without obvious cause, the patient’s attention being
attracted to a stiffness in the palm, and an incapability of
completely straightening one or more of the fingers. The
contraction and stiffness increase, until the tip of the ring
or middle finger is drawn completely into the palm, greatly
interfering with the functions of the hand. The contracted
condition of the finger is constant, not varying in extent
at different periods, as some contractures from other causes.
Its progress is slow, several years elapsing before the defor¬
mity attains the highest grade.

An examination of the finger shews that the deformity
is maintained by an* indurated, inelastic, hypertrophied
condition of the palmar fascia. The individual retains the
power of flexing and extending the finger, within the range
permitted by the contracted fascia. A tense cord is per¬
ceived extending along the Fig _ 79t

palm, towards the most con¬
tracted finger, in part aris¬
ing from shortening of one
of the flexor tendons thrown
into relief by its contraction.

The habitual state of the
hand in the individual from
whomthismodel (fig. 79) was
taken, was one of greater
contraction; the model rep re¬
sents the appearance when
the patient endeavoured, by
muscular action, to extend

Contracture of fingers from disease of
■ palmar fascia.1

* Since the above was written the author has witnessed conjoint affection
of all the fingers, the thumb and forefinger having been less affected than the
remainder.

f This complaint is often hereditary. It is difficult to determine what
complaint is not hereditary.

180

PATHOLOGY OF DISEASED FASCIA.

the fingers. The pathology of this affection is interesting.
From the [usual] inability of patients to assign any cause
for the contraction, I have been induced to search for it in
some abnormal condition of the general system. I have
witnessed instances of the contracture in persons of different
trades and professions,—coachmen, bakers, artisans, clerks,
and individuals of the richer classes following no manual
occupation. It usually affects both hands, though in dif¬
ferent degrees, and sometimes the soles of the feet present
a similar affection of the plantar fascia. Every patient had
suffered from some form of dyspepsia, from rheumatism,
and lithic acid urinary deposits; and the majority admitted
that at some period of their lives they had partaken freely
of wine or other fermented liquors. Hence a rational
pathology leads to the conclusion, that this induration and
thickening of the fascia is one of the forms in which a
rheumatic or arthritic diathesis manifests itself. It is ap¬
parent that the affection of the fascia is primary, and that
the contraction of the flexor tendons is secondary, consist-,
ing of structural shortening from long continuance of the
deformity, independent of any lesion or innervation of the
muscles of the fore-arm.

[One gentleman attributed the complaint in both hands
to his having, as a workman in some branch of the useful
arts, been employed for many hours daily, during several
years in early life, polishing metallic surfaces by means
of emery with the palms of the hands.

The constitutional cause may sometimes be only the.
predisposing cause, a local injury the exciting cause of
this.affection.]

Treatment .—Subcutaneous section of one or more of
the bands of contracted fascia, extending towards the fin¬
gers, and of the subjacent flexor tendons. These operations
should be done in the part of the palm where the tension is
most evident, and with the view of preventing adhesion of
the tendon to other divided structures, as in a cicatrix.

TREATMENT.

181

I have preferred severing the tendon apart from the fascia.
I have witnessed no case in which the puncture has not
healed by adhesion within forty-eight hours. After adhe¬
sion the contracted fingers should be gradually straightened
by being bandaged on a splint. It is not desirable to effect
this part of the treatment too rapidly, as great pain will he
produced by the attempt. Three weeks or a month usually
suffice for removal of the resistance presented by the various
textures of the palm that have been long contracted,—for
it should be remarked that the abnormal condition of the
fascia renders the palm unnatu¬
rally concave. The use of the
fingers is entirely restored, and
at the expiration of a few months
the induration and thickening of
fascia being slowly removed by
absorption, no trace of the de¬
formity will remain, as in this
model (fig. 80), which represents
fig. 79 after the cure. In this
case section of the band of fascia
and of the tendon proceeding to
the middle finger, was the only
operation requisite; the conse¬
quent relaxation of the fascia and loosening of the palm
permitted the complete straightening of the remaining fin¬
gers.

[Slight cases of this nature yield to moderate con¬
tinuance of mechanical treatment alone; and even in severe
cases, when from age of the patient, or other circumstances,
it is undesirable to do even the slightest operation, great
amelioration is obtainable from manipulations and gentle
mechanical treatment.

These cases are apt to relapse if manipulation or the
diet be neglected. The subject of fig. 80 has three times
in eleven years requested me to repeat the operation. The

182

DISEASED CERVICAL FASCIA.

relief is so complete, and its permanency so much under
the control of the patient, that this tolerance of the trivial
operation is not surprising. In consultations it has been
objected in toto to the operation, that the contracture is
apt to return; to which it may be replied, that the contrac¬
ture in question differs not in this respect from thoracic,
abdominal, or indeed from the majority of internal local
diseases, which tend to return on fresh application of the
remote and exciting causes, or neglect of the means en¬
joined to prevent relapse.]

Similar contracture of a finger from a wound of the
palm, or of the finger itself, although the wound may have
united by adhesion immediately after the injury, is not
unfrequent. The treatment should be conducted on the
principles already laid down.

[A rare case of neck-deformity from disease of cervical
fascia (figs. 81 and 82) is here introduced, from its analogy

Fig. 82.

Fig. % 81.

to contracture of hand and fingers induced by disease of
palmar fascia. The neck was almost immovable, and the
chin firmly bound and inclined towards the sternum by
the indurated and hypertrophied fascia. The constitu¬
tional powers of the patient had been reduced by the com¬
bined influence of “ rheumatic fever,” syphilis, primary

CONTRACTURE OF FINGERS.

183

and secondary, and mercurial ptyalism. The contracture
had existed about six years.*]

The spasmodic contractures of the fingers are more
complicated in their pathology, and more difficult and un¬
certain in their treatment. This state is often associated
with spastic affection of the wrist and arm, as in this model
(fig. 31, p. 109), with spastic affection of the toes, or of
the face or neck. You will experience no difficulty in
distinguishing it from paralytic contracture, which it so
greatly resembles in appearance, by remarking that the
patient possesses power of volition in the extensor muscles,
but that these muscles are overpowered by the spasmodic
condition of the flexors. The contraction of the flexors
is often more convulsive or clonic than spastic.

Here are models illustrative of the different grades.
In the majority the thumb is firmly drawn into the palm.
I cannot speak favourably of tenotomy when practised
where the tendons are enclosed in the thecse, but when
effected in the palm it has proved more successful. In
some instances, where the affection was combined with
abnormal flexion of the wrist, I have divided the flexor
sublimis digitorum, the flexor longus pollicis, flexor radia-

* The patient, a female, aged 40, who had borne a large family, many of
the later children having been still-born, was admitted into the London Hos¬
pital on several occasions during the years 1846, 7, 8, on account of neck-
contracture, syphilitic nodes on sternum and ulnae, painful tibiae without
nodes, ulcerated sore throat, and general debility. She derived benefit from
potash iodidum, quinine, and generous diet. She was admitted on the last
occasion for severe erysipelas of head, face, and neck, and double pneumonia.
During the progress Of the erysipelas an abscess formed in the neck, and dis¬
charged at pomum adami. She sank on fourteenth day of the acute disease.
Autopsy; consolidation of inferior half of both lungs, with incipient purulent
infiltration. The neck-contracture was found to depend upon cartilaginiform
induration, with hypertrophy of superficial and deep fasciae of front of neck.
The platysma, the stemo-hyoid, thyroid, and mastoid muscles, were struc¬
turally shortened, and presented unusual firmness, and appeared to have par¬
tially undergone fibrous transformation. The patient had also been affected
with induration of fascia on calf of leg, which had yielded to the topical ap¬
plication of iodine.

184

writer’s cramp.

lis and ulnaris, above the wrist, with much advantage.
The operation has been less directly beneficial in restoring .
the use of the member than as serving as a starting-point
for improvement. Thus, the patient after the operation
is sensible of the removal of a powerful obstacle to the
action of the extensors, and is enabled to use them more
effectually in controlling the remaining active flexors (for in
these cases the flexors generally are involved). Persever¬
ing education of the muscles becomes necessary for the
obtainment of a useful member. In some instances I have
succeeded so far in restoration that the individual has been
enabled to use the hand in coarse manipulations, and in
one case to write tolerably well.

[Spastic contraction of muscles of the hand induced by
excessive use of particular muscles, as in excessive writing
(Schreibekrampf of the Germans), or from excessive use of
the fingers in instrumental music, as at the pianoforte, are
occasionally met with in adults (unaffected with chorea). A
very slight affection of this nature, amounting only to an
occasional jerk of the pen, is not uncommon in persons of
enfeebled nervous system who write in a hurried manner.*
A similar affection is more common in the facial muscles.
Stromeyer has found division of the flexor and opponens
pollicis muscles beneficial. Dieffenbach has severed the
orbicularis, zygomatici, and levator anguli oris in a severe
case.j- Tonics, attention to general health, and removal of
predisposing and exciting causes, constitute the preferable
treatment. Sometimes the affected writer can direct the
pen if it be passed through a thick piece of cork, which is

* “ The nerves that in artists or mechanics have been developed by spe¬
cial practice of a part are liable to become the seat of spasmodic action.”—
Romberg, Manual of Nervous Dis., Sydenham Soc. transl., vol. i. p. 284.

f Stromeyer, Beitrage zur operativen Orthopadik, 1838. Dieffenbach
iiber die Durchschneidung der Muskeln und Sehnen, 1841.

Froriep “ on Electro-Magnetism,” translated by Dr. Lawrence, 1850, re¬
ports cures by the use of this agent. The excellent Berlin surgeon does not
mention what dietetic, social, or hygienic treatment he may have simultaneously
employed. See observations on electricity, p. 45 of this volume.

writer’s paralysis.

185

more easily grasped than a smaller substance. An opera¬
tion is justifiable, as in the analogous case of spasmodic
(clonic) jerking wry-neck(pp. 120, 192), when the patient’s
livelihood is endangered or his state of mind and body is
impaired by the protracted existence of the complaint.*
Paralysis of one or more muscles of the hand from excessive
use, as in writing for example,-j- or at the piano, J is more
frequent than protracted clonic spasm. §

Great improvement may he effected in the spasmodi¬
cally affected hands of children partially idiotic or im¬
becile, simultaneously with the improvement effected in
the mental and remaining corporeal condition of the in-

* The occurrence of this abnormal muscular action (spasmodic) of muscles
which have been inordinately physiologically used, seems pathologically allied
to the state which occurs, it is stated, to some omnibus-conductors, who are
unable to sit still at meals after habitual jolting upon their standing-board.

+ “ Mr. A. B„ aged 35, since boyhood engaged writing greater part of
the day, and often at the Clearing House in the City until after midnight,
the nature of his duties requiring him to write very quickly, has lost the power
of holding and guiding the pen without any spasm. Other muscles of the
hand and wrist are unaffected. He appeared of nervous temperament, in¬
duced by late hours, exciting hurried nature of occupation, and habitual inat¬
tention to regular hours for taking food. He was recommended a tonic
regimen, to abstain from writing, and three months’ sojourn at sea-side.
After a few weeks’ adoption of this prescription he had improved, but the
ultimate result has not yet been ascertained.”

J “ A lady, aged 26, teacher of the pianoforte in a fashionable watering-
place, free from hysteria, not robust, but complaining of no derangement of
health except occasional suffering at catamenial periods, has entirely lost the
power of the right little finger. Debility was first perceived five months ago.
The fleshy mass of the internal palmar region, consisting of the abductor,
flexor brevis, and adductor minimi digiti, is obviously wasted. The remote
cause of the ailment appears to be exhaustion of nervous system, induced by
anxious attention to duties, much hurried bodily fatigue incurred in hastening,
on foot from one appointment to another during the mid-day hours, the habit
of passing nine or ten hours without food after only a slender breakfast; whilst
the exciting cause is the lengthened hours of ‘ practice’ at the piano after her
duties of teaching are ended. Tonics, more generous animal diet, food taken
at shorter intervals, temporary discontinuance of ‘ practice,’ and the resolu¬
tion less readily to embrace every fresh engagement offered to her, effected
restoration in the course of six months .”—Extracts from Author's Case-book.

§ The analogy of these eases of peripheral paralysis with that narrated at
p. 166 is complete.

186

SPASM EXCITED BY ACT OF WILLING.

dividual. Sometimes children, who have the condition
already described under asphyxia neonatorum, exhibit con¬
vulsive (clonic) movements of the wrist and fingers when¬
ever they attempt to use the part. Contact of the hand
with the pen, or the direction of volition towards the mem¬
ber, calls the aberration of motility into action. This will
remind the reader of the aggravation of Talipes when the in¬
dividual attempts to walk (p. 146), and of the cases in which
deformity is present only when use is made of the part—
the limb when at rest presenting no abnormal appearance.
This intermitting spastic action of muscles (called forth on
contact of sole with ground, or by the direction of voli¬
tion to the part,) reaches its maximum in some instances
of universal spastic rigidity of young children, and occa¬
sionally after hemiplegia in adults.* Thus the author has
under treatment a lady, aged 56, who had hemiplegia a
year ago ; the paralysis has disappeared, but most painful
tonic spastic contraction of gastrocnemii, anterior and pos¬
terior tibials, flexors of toes, and apparently extensors of
toes, occurs the moment she attempts to stand, and con¬
tinues so long as she perseveres in the attempt, rendering
locomotion impossible. Sometimes the knee is suddenly
bent from the same cause, exposing her to sudden falls.
Allied to this case of spasm is a case observed by the
author in a gentleman, aged 42, of active literary and
professional habits, in whom perhaps also a predisposition
to nervous disease was acquired in infancy. He suffers
in a slight degree from writer’s cramp ; but when engaged
in disproportionably severe use of the hand, as in saw¬
ing wood (grasping the hand-saw with the right hand), or
using a hammer, the fingers are sometimes involuntarily
clenched, preventing him from disengaging the hand from
the tool. He relates that on two occasions after driving a
pair of horses a long journey, the mind having been some¬
what tried by restiveness of the animals in descending a

* See case of this description, Stromeyer, opus cit. p. 94. Symbolse ad
Talipedem Varum cognoscendum, W. J. Little, Berolini, 1837> p. 74.

CONTRACTURE AND IDIOCY.

187

steep hill, the whip-hand became suddenly spastically and
painfully closed, some seconds having elapsed before the
use of it was recovered. The influence of emotion in
withdrawing nervous influence from volition (whilst most
powerfully willi ng) was quite perceptible.

As the author is not engaged in writing a treatise on
diseases of the nervous system, he refrains from pursuing
the subject, notwithstanding its intimate association with
the pathology of deformities, but refers the reader to
Romberg opus cit.

In the clonic hand-spasm of children affected with more
or less general spastic rigidity, the author has derived much
benefit, without tenotomy, from manipulations, the appli¬
cation of an instrument to the fore-arm, the wrist, and
palm, furnished with a hinge opposite the joint, and a gun-
lock spring to aid the weak extensors in maintaining ex¬
tension. He has also for the same purpose adapted thin
springs along the dorsal surface of the fingers. He has
enabled such individuals to write legibly with the pencil.
In some cases education of the hand and fingers has been
continued many years, before the individual could carry a
fork or glass in safety to the mouth. He has observed the
same slow acquisition of voluntary power in cases in which
the. intellect was but little below average ability.*]

* Amongst the most gratifying effects of medical practice, the author
may advert to the mental and bodily improvement in cases of spastic rigidity
combined with apparent almost total absence of intellect. Twelve years ago
he commenced the treatment of a young gentleman, partially imbecile and
much deformed, in whom the attitude of head and trunk, the crouched sitting
posture in the comer of a sofa, the retracted lower extremities (the awkward
gait upon the toes when locomotion was with assistance attempted), the hands
useless, the low development of forehead and smallness of head, the retentive
memory of acts of kindness or the contrary, the inability to utter other than
animal inarticulate sounds, the painful “ roar” when anger or grief overcame
him—all reminded the observer more of the Simia tribe than of a human being.

Yet such has been the progress during twelve years, that speech has been
acquired, although still indistinct when mentally excited; he can hold the head
erect, keep the mouth closed, and prevent escape of saliva; locomotion and

188

NON-CONGENITAL WRY-NECK.

Another deformity, constituting a contracture, is the
non-congenital wry-neck, or caput obstipum.

This affection is characterised by an inclination of the
head to one side, and a peculiar rotation, as in this drawing
(p. 107), through which the ear is approximated to the
upper part of the sternum. In some cases the defor¬
mity is so considerable that the head almost rests on the
shoulder.

You will, from my classifying this affection with con¬
tractures, at once conjecture that it may be produced by a
variety of causes.

Any circumstance, in short, that tends to disturb the
equilibrium of the muscles which are attached to the
thorax and to the head may induce the deformity at any
period of life—spasmodic contraction, paralysis, rheuma¬
tism, voluntary inclination of the head to one side during
painful affections of lymphatic glands, during vesication
from cantharides and other irritating applications, or the
cicatrix of a burn. Many of these causes act generally on
the muscles of one side, and the deformity may, in the first
instance, consist only of a simple leaning of the head to that
side; but in consequence of the bulk and power of the
sterno-cleido-mastoideus, and the freedom of its course,
being unattached except at its extremities, this muscle
promptly usurps a predominant influence, even when not
specially affected, and converts a simple yielding of the
head into a complicated deformity. The diagram before

horse-exercise without assistance have been achieved, although caution is needed
to prevent accidents; he can write legibly with pencil, can use knife and fork,
hold a tumbler with both hands, notwithstanding he is still liable to choreal
movements if excited or bodily indisposed ; his temper is controlled to the ex¬
tent that he is an amiable member of society ; the physiognomy has become
comparatively intellectual, and the anterior region of cranium positively en¬
larged. Although this gentleman, now an adult, will ever remain inferior to
the majority of men in his mental and corporeal endowments, the progress
made possesses intense interest for the physiological pathologist.

VARIETIES.

189

you exhibits a slight case ; when more severe the opposite
shoulder is greatly depressed, and a curvature of the cervical
vertebras induced. An attentive examination will enable
you to discover the structures which principally impede the
restoration of the position of the head. The most promi¬
nent, and in many cases the sole resistance is afforded by
the sterno-cleido-mastoideus. Sometimes the tension of
the trapezius evidently modifies the deformity, and often
the more deeply situated muscles appear involved, although
the belief in this universal muscular affection is derived
rather from observation of the effects of treatment than
from examinations previously to it. In the majority of
instances the sternal portion of the sterno-cleido-mas¬
toideus alone appears tense; sometimes the clavicular
portion is especially contracted, in which case the clavicle
becomes deformed, and the central part is drawn upwards
(p. 1.19).

The patient is unable to rectify the position of the
head, and seldom will you succeed in accomplishing it by
forcible manipulation.

The spastic form of non-congenital wry-neck is the
most common, and occurs suddenly or gradually, from dis¬
ease within the nervous centres, manifested, for the greater
part, through the instrumentality of the spinal accessory
nerve, of which the filaments are distributed to the sterno-
mastoideus and trapezius muscles. Sometimes the spas¬
modic contraction is transient [clonic], or much augmented
under emotion; at other times the tension of the muscle
is constant, and structural shortening usually exists to a
greater or less extent. The paralytic form is not unfre¬
quent ; in these cases the deformity is maintained by con¬
traction of those muscles which are deprived of antagonists.
Wry-neck consequent upon instinctive retention of the head
on one side occurs, almost exclusively, in young persons.
In these the deformity is rapidly produced, apparently
in consequence of the continued growth of the vertebral

190

DIAGNOSIS OF VARIOUS

column and of the structures on the side of the neck
towards which the head does not incline; whilst the growth
of parts on the inclined side being retarded, a dispropor¬
tion between the muscles on the two sides is produced.
The deformity resulting from burns is usually of a compli¬
cated nature, as the tension of cicatrices, resulting from
loss of substance, is added to the muscular shortening in¬
duced by long-continued rest in a certain position.

Deformity similar to wry-neck is sometimes produced
by disease of the cervical vertebrae.*

[Cases not unfrequently occur of disease of the lympha¬
tic glands of neck, in which some obliquity of the head is
assumed. In more severe cases the deeper-seated glands
are involved, with comparatively little external swelling,
the resemblance to wry-neck as regards attitude of head
being very striking.

Occasionally an attentive examination is required to
determine whether disease of the vertebral column, its
osseous or ligamentous structures, co-exists. In this case
the glandular disease and obliquity of head are but the
symptoms of the deeply-seated more urgent affection.
As aids to diagnosis among these different forms of head
deviation, a few practical rules may be serviceable.

The first circumstance to be ascertained is the existence
or absence of voluntary action in the sterno-cleido-mastoid
muscle. By this test the absence or presence of paralytic
affection may be determined. In the spastic affection
volition is not always abolished. The existence of struc¬
tural shortening, if any, should be ascertained by measure¬
ment and the touch.

As structural shortening is slowly produced, it points
more commonly to spastic, paralytic, or congenital origin,
than to the influence of cervico-vertebral and glandular
disease. If deeply-seated glandular disease, or vertebral

* The author has seen deformity resembling wry-neck from injury at
base of one side of neck involving the clavicle, produced by a gun-shot wound.

FORMS OF WRY-NECK.

191

disease, be suspected, the co-existence of strumous signs
elsewhere may be sought. Disease of ligaments or bones
usually occasions more or less well-marked constitutional
disturbance, characteristic of strumous disease in other
articulations : wasting, paleness, diminished appetite, pre¬
ference for fluid aliments, skin warmer than natural or
relaxed, frequent pulse, disturbed sleep, nocturnal moans
and cries, morning perspiration, jurina umentosa ; the elas¬
ticity of child’s disposition, however, permitting exercise
and attention to ordinary pursuits, although these are
accompanied with early fatigue.

The treatment of wiy-neck deviation from disease of
vertebral column is conducted upon ordinary principles
(in severe cases repose of the part in a suitable mechanical
contrivance, see Spinal Curvatures), counter-irritation by
tinct. iodinii comp., internal use of steel, quinine, iodine,
ol. morrhuae, and, above all, residence in a pure dry at¬
mosphere.]

Treatment. —Non-congenital wry-neck requires treat¬
ment conducted on principles similar to that of other con¬
tractures. In the spasmodic and paralytic forms, if the
deformity have not existed many years, you may employ
the general remedies applicable to disease of nervous cen¬
tres, already enumerated, seldom with complete success.
Should the deformity be recent, and have proceeded from
rheumatism, disease of cervical glands, or any local cause
exterior to the central organs of the nerfous system, the
removal of the local affection, by appropriate topical and
other remedies, must be effected previously to special treat¬
ment of the deformity. If the origin be satisfactorily
proved to be voluntary retention of the head on one side,
continued vesication or other painful counter-irritation on
the opposite side may be resorted to with advantage. I have
in two instances witnessed the success of this plan. In all
cases except the spasmodic and paralytic, and after sub¬
sidence of acute disease, benefit will be derived from
[careful] manipulations of the head and neck, exercise

192

TREATMENT OF NON-CONGENITAL

of the weakened muscles, and the wearing of a stiff leather
or pasteboard collar, properly padded, and proportion¬
ately higher on the depressed side of the neck. In
every case in which structural shortening of the sterno-
cleido-mastoideus exists, tenotomy of one or both of the
origins of the muscle may be effected. Sometimes section
of the sternal portion is sufficient, but instances occur in
which the cure will not ultimately be effected without
section of the clavicular portion. You will remark in these
cases, that after the resistance of the sternal portion is re¬
moved, the clavicular becomes daily more prominent, and
partially retains the deformity. In severe spasmodic cases
subcutaneous tenotomy is especially useful; it does not
always effect a complete cure , because the disease resides
in the central organs of the nervous system, which teno¬
tomy cannot affect. But the operation, succeeded by
appropriate treatment, lessens the energy and power of the
muscular contraction, relieves the distressing neuralgic and
other pains accompanying this form of deformity, and ren¬
ders more effectual the use of the mechanical means that
may subsequently be required.*

[The author operated one case in an elderly female,
who for years had not slept soundly through pain and the
incessant convulsive movements of the head. She had in
vain endeavoured to obtain rest in an arm-chair. After
the operation she slept well; but the case was not other¬
wise successful, for the spasms returned, and she sank soon
afterwards from another disease.]

Tenotomy serves also in many instances to attain the very

* “ For certain forms of spasm modern surgery has introduced myotomy;
a proceeding which not only removes the residuary effects of spasm, contrac¬
tion of the muscle (retraction of the French, structural shortening of the
author), but may also exert a beneficial action in calming the nervous irritation
during the persistence of the spasm.”—Romberg, opus cit. p. 289. Elsewhere
Romberg points out the unfavourable results of treatment of clonic neck-
spasm. Sir B. Brodie many years since observed ( Theory of Local Nervous
Affections, p. 32), that in “ muscular spasms remedies are of little avail.”
Stromeyer, Manual of Surgery, 1845, vol. i. p. 268 : “ Tenotomy relieves
spasm in about the same manner that opium relieves other cramps.”

WRY-NECK.

important object of enabling tbe muscles that have been long
overpowered to recover a large portion of their lost vigour.

I have witnessed the necessity of repeating the operation
in a severe case of this nature. Stromeyer relates a similar
case. I believe the relief afforded by tenotomy, in very
active spastic cases of wry-neck, to be so considerable,
whilst the pain and inconveniences of the section are so
trivial, that a person thus affected may be readily willing
to consent to its repetition.

Tenotomy does not, a priori, appear indicated in a
paralytic case; yet if structural shortening exist, the section
may properly be resorted to, simply as a means of restor¬
ing the position of the head, and facilitating its retention
by an appropriate cravat.

Various ingenious contrivances have been proposed for
maintaining the head in a proper position, either after
tenotomy or when the operation is unnecessary: the most
notable of these is that of Jorg.* It does not completely
answer its purpose. The cravat is more commonly employ¬
ed. The most simple and effectual consists in encasing
the head with a common bandage, and in securing it by
means of appropriate slips to the shoulder, or to any part
of the dress of the individuals.

[After trial of numerous mechanical expedients for wry¬
neck, treated with or without tenotomy, the author finds
nothing equals the efficacy of a few strips of spread empl.
plumbi and a roller bandage. The difficulty ordinarily ex¬
perienced arises from the form of the parts, the position of
which we require to amend readily permitting the bandage
or apparatus to become detached. Regarding the trunk as a
fixed point, the surgeon seeks to act upon the movable head
in such a manner as to cause a rotation of it in a direction
contrary to the abnormal deviation. In whatever direction
the head be bandaged (omitting the face), the surgeon
has to deal with a part more or less globular or oval, from

* J. C. G. Jorg iiber die Verkriimmungen des menschlichen Kcirpers.
Leipzig, 1810.

194

BURN-CONTRACTURES.

which, or around which, any cap or bandage, when traction
is exercised upon it, is prone to glide, the therapeutic
effect of the apparatus being at once rendered nugatory.
Spread emplastrum plumbi, by its adhesive properties,
presents a material which does not readily detach itself.
A band one and a half inches broad may evenly and not
tightly encircle the forehead and occiput, and be kept
in close apposition by a few turns of a roller bandage over
it. A similar contrivance should be applied around the
waist. A tape should then be sewn to the plaster and the
superimposed bandage, immediately in front or behind the
ear, according to the existing indication, as regards depres¬
sion of chin or of occiput, in addition to the main object
of rotating the head. The tape should pass diagonally
downwards across the neck and chest towards the opposite
side, and its lower extremity should be secured to the
waistband as much towards the opposite side of the trunk,
and as tightly as may be required, to effect rotation of the
head. Daily attention to the details of the bandage is neces¬
sary. Ordinary dexterity in bandaging on the part of the
operator, and a few repetitions of the application, will fami¬
liarise both himself and patient with this simple, secure, and
effectual mode of mechanical treatment of wry-neck.]

Deformities of the head and neck from burns are rarely
remediable. Tenotomy may occasionally be useful; but
the plastic operations are more frequently serviceable. I
cannot speak of these from my own experience, and there¬
fore shall not detain you longer on this subject.*

[The deformities resulting from cicatrices after burns
in the extremities are more favourable, and are often re¬
mediable by manipulations and suitable bandages, splints,
or mechanical apparatus, or by subcutaneous or open
division of the cicatrix, and subsequent gradual extension.
The author has never found it requisite to follow Dupuy-
tren’s recommendation of making several transverse inci-

* Prof. Mutter, of Philadelphia, has been one of the most successful
plastic operators in severe burn-contractures.

TREATMENT.

195

sions at short distances throughout the length and thick¬
ness of the hand. On the contrary, one section across the
■whole breadth and depth of the abnormal hand of tissue,
in the situation where it is most free from adhesion to deep-
seated structures, has invariably enabled the author to re¬
store the parts whenever attempted, as in the elbow, wrists,
and fingers, after the neck, the most common situation of
these contractures.

Several transverse incisions in the less organised tissue
of a firm cicatrix would appear liable to induce inflamma¬
tion or death of the intervening portions, by partially cut¬
ting off the supply of blood from them. If several inci¬
sions were requisite, they should he successively effected,
after healing of the section already made, and in proportion
as they may appear necessary.

Mechanical treatment is on common principles avail¬
able in slight cases :* but where the web-like hand or the
bridle of new tissue is large, much
time, and the suffering incidental to
protracted wearing of instruments
which exercise tension, are saved by
section of it. Thus cure of web-like
burn - contractures of the severest
kind, in an extremity, maybe effected

in six or eight weeks. The operation_

us painless, as the parts severed are EIb0W contracted by web-me
not supplied with nerves, and often hand suiting from bum.

almost bloodless, as the blood - circulation is after a time
indifferent in new tissue (tissu inodulaire ). The web-like
substance, or the bridle, immediately shrinks, and often in
the space of two months entirely disappears, f

* “ C’est souvent dans les cas de cicatrices a la suite de brulures que les
appareils mecaniques peuvent rendre de grand service.” — De VApprecia¬
tion des Appareils Orthopediques, par E. Chassaignac, p. 127, Paris, 1841.
Chassaignac relates the success thus obtained by Dutertre in 1814.

f July 1848.—Ayounglady, aged 15, residentin a part of Australia remote
from medical aid, was eight years ago severely burnt on the left side of the face

196

BURN-CONTRACTURES.

Fig. 80.

Deformity of foot from con¬
traction of cicatrix after
burn, see p. 2C0.

In some burn-contractures the con¬
tracting band is less web-like, resem¬
bling rather the cicatrices which occur
after suppuration, as in fig. 80.

Even burn-contractures of more un¬
favourable aspect, those in which adhe¬
sion of surfaces exist, and the operative
treatment of which is usually considered
to be less successful, admit of relief.

The treatment of a case of this de¬
scription may require to be spread over
a long period, in consequence of the ne¬
cessity of avoiding several suppurating
surfaces in the palm at the same time.

and chest and on the left arm. The burns of the chest and face healed in
a few weeks ; but the suppurating surface, extending from the axilla to palm
of hand, which had been complicated with sloughing, did not cicatrise until
many months after the accident. She has since been completely deprived of
the use of the elbow and wrist, which are contracted, the elbow being flexed
to a right angle, the wrist flexed and pronated. Opposite the elbow is a firm,
whitish, web-like substance, in parts half an inch in thickness, originating
from the middle of the upper arm, reaching to the wrist, where it spreads out
into two portions—the one inserted into the ulnar region of the palm, the
other into the radial portion. The movements of the fingers are tolerably
free. The father, by profession a civil engineer, had displayed much ability
in the construction of mechanical instruments for extension of the elbow, and
was not a person to be daunted by slight difficulties; but he had never been able
to make more than a temporary impression upon the band of adventitious tis¬
sue. The hand and arm were from disuse much smaller than the sound mem¬
ber. The uncommon thickness of the abnormal band, and its numerous firm
connexions with the deeper structures, indicating that the original bum had
penetrated to the fasciae and muscles, rendered it improbable that manipula¬
tions and mechanical extension of elbow would remove the contracture. Th
following operation was consequently performed, July 13, 1848, with the
assistance of Mr. Hamilton and Mr. D. Nelson of Acacia Road :

The elbow was rested upon a table, one assistant holding the shoulder, whilst
another stretched the abnormal band by depressing the fore-arm. An ordi¬
nary sharp-pointed bistoury was passed through the web immediately above
what was considered to be the tendon of the biceps, and the web completely

MECHANICAL AND OPERATIVE TREATMENT. 197

In that represented at fig. 81
taching with a scalpel the little
finger from the palm, using ex¬
tension upon the phalanges
during the proceeding. He was
gratified at finding that the
finger could be straightened,
leaving a wound extending
throughout the long axis of the
finger, and nearly midway up
the palm. The laxity of tissue
in the palm permitted the ap¬
proximation by sutures of the
palmar portion of the wound,
but little closure of that along
the finger could be effected. It
was hoped that by granulation
this portion would close with¬
out recontraction. A month
after the operation reunion was
complete, the finger having been
kept extended upon a whalebone
splint. A similar operation was
performed upon each of the re-

the author began by de-

Contracture of hand after burn. Tile m
•whole of the fingers and the thumb
were adherent by the entire width of
their palmar surfaces, some more
completely than others. Thus the
thumb and forefinger were firmly ag¬
glutinated to the palm to within half
an inch of their terminal extremities,
whilst the third, fourth, and fifth
fingers were adherent quite to the
extremities. The patient was a boy,
aged eleven. The burn occurred
six years before the period of the
operation resorted to for restoration.

severed from behind forwards. The contracture instantly diminished up¬
wards of one-half. A few dense fibres were felt in the resulting wound opposite
the elbow; these were severed by a touch with the point of the bistoury, with the
effect of further reducing the contracture ; whilst the joint appeared so supple,
that no doubt existed that if it were advisable the elbow could at once have
been entirely straightened. An ounce of venous blood oozed from the divided
surface, which was about four inches in length, and in parts an inch and a half
wide. The sides of the wound were brought together as much as possible by
a few ligatures, to the extent of reducing the surface one-half. Oiled lint was
applied as dressing, and the limb bandaged upon a splint in the new position,
but without exercising any tension upon the parts. It is unnecessary to pub¬
lish the details of the case during the cicatrising and extending process ; it is
sufficient to state, that a linear scab only remained at the end of the eighth

198

BURN-CONTRACTURES.

maimng fingers, the entire treatment having occupied about

Fig. 82.

This drawing represents the hand, fig. 81
after the treatment.

catrix prone to contract.

six months. The accom¬
panying drawing, fig. 82,
represents the amount of
improvement obtained. At
the present time (Jan. 1853),
eight months after the ope¬
ration, the power and move¬
ments of the thumb are per¬
fect, the fingers are almost
perfectly free in their move¬
ments'; he can grasp small
as well as large objects with
facility, and may truly he
said to have benefited by the
operation to the extent of
regaining a hand.

The little and middle
finger present on their pal¬
mar surfaces a cord-like ci-
The patient has been recom-

week ; a fortnight later this had become detached; the elbow was perfectly
straight and flexible. The wrist did not require operation, as the relaxation
afforded by elbow-operation relieved much of the flexion of the wrist; the
remaining flexion and pronation was overcome by manipulations and use of
the hand. On Sept. 6, 1848, she was able freely to bend and extend both
elbow and wrist, and employ the hand at the piano. The author has since
frequently seen this young lady; the restoration has been perfect and con¬
stant. No portion of the band remains.

The following case occurred in a younger subject: the web (see fig. 79)
was as extensive as in the former case, but thinner and less dense. The
subject, a girl, aged 7, who had been badly burnt two years before, was
seen, in consultation with Dr. Aitken, Kingsland, May 1850. The left arm
was contracted to a right angle; the band was divided as in the above case ;
the elbow was immediately straightened without difficulty; a few drops of
blood only flowed. The more superficial nature of the case enabled the edges
of the wound to be brought almost into apposition, with the assistance of a
few ligatures. Cicatrisation was completed within fourth week, a narrow,

TREATMENT.

199

mended to wear at night, during the growing period of life,
a five-fingered metal hand-splint, for the purpose of pre¬
venting re-contraction. Under any circumstances of neglect,
he cannot relapse into his former state.*

smooth, shining scar alone indicating the situation of former band. The func¬
tion of the arm was entirely restored within six weeks.

Mr. Adams, of the Royal Orthopaedic Hospital, very recently shewed me
a model of a similar burn-contracture of arm, successfully treated there by Mr.
Tamplin, by twenty weeks’ incessant mechanical stretching.

* A fourth case of burn-contracture is added, for illustration of the extent
to which restoration may be effected without dissecting out of cicatrix or trans¬
plantation of integument. The author was consulted by Mr. Lallemand, of
Macclesfield, respecting a young lady whose left hand, after a severe burn, was
helplessly contracted. The position of the hand resembled that represented
p. 109. The contraction of elbow was inconsiderable. Traces of the burn
were visible both on the anterior and posterior surfaces of the arm and wrist.
The cicatrix on the back of wrist represented a thin glistening skin spread
loosely over it, whilst on the front of the wrist and fore-arm were two thick
indurated bridles ; the smaller extending from above the inferior extremity of
ulna towards the elbow; the larger and broader, springing from opposite the
base of the thumb, traversed the f6re-arm to the elbow, uniting the smaller
bridle with it, and serving to limit the movements both of wrist and elbow.
It also sent a prolongation into the palm, which effectually prevented the use
of the thumb. The front of the wrist was so completely occupied with dense
cicatrix of fibro-cartilaginous hardness, as to occasion doubts of success with¬
out transplantation of integument from the posterior part, where it existed
in abundance. The author determined to sever the principal band on the
radial surface of the wrist, to detach the integuments on the radial side of the
gap made by the section of the band, and endeavour to bring some of the
loose integument with the aid of ligatures from the posterior towards the
anterior aspect of wrist, and trust to mechanical extension for elongation of
that band which extended from the hypothenar upwards.

The operation was accordingly performed (August 25, 1851), and the
wrist gradually extended during cicatrisation, which took place uninterrupt¬
edly in three weeks. At expiration of five weeks the wrist was fully extended
and supinated; the palmar band, which firmly bound down the thumb, also
yielded considerably to the constant stretching employed ; but more complete
liberation of this part was effected by dividing the portion of the band which
extended from the thenar towards the extremity of the thumb. The band
over the ulna also gradually yielded, whilst the elbow was liberated by the
operation upon the larger band and by mechanical extension. The entire
restoration of the form and movements of the wrist and thumb was effected

200

BURN-CONTRACTURES.

The author’s experience of the division of burn-cicatrices
is so favourable, that he is of opinion that greater reliance
upon this plan, combined with painstaking mechanical
treatment, will complete the abandonment of the mode
formerly advocated by Earle and Dieffenbach of dissecting
out a cicatrix, and will greatly reduce the necessity of the
awful baring of surface required for successful transplanta-

within eight weeks. She now began actively to use the hand during the day¬
time, wearing the splint at night only. Four months after the operation, all
bridles having disappeared, the volar surface was perfectly smooth; and the
hand, although it had been entirely disabled during eight years, was free from
deformity, and restored to usefulness. The share which the partial detach¬
ment of integument had in filling up the gap formed by the division of the
bridle is shewn by the form of the cicatrix resulting from it. The gap after the
operation was about two inches and a half broad, and presented the following

outline

The smooth cicatrix had the following shape

<]•

shew¬

ing that the endeavour to bring some integument from the side had suc¬
ceeded. In order to prevent recontraction, this case was kept under obser¬
vation some months after restoration of form and movements was effected.
Mr. Lallemand has since informed the author that no relapse has taken place.*

* The case, fig. 80, p. 196, was successfully operated by Mr. Gowlland,
by open division of the cicatrix ; and illustrates the promptitude with which
restoration may be obtained. He has kindly furnished me with the following
report of the case:

“ At the time of the operation the outer side of the foot was forcibly drawn up, and
entirely prevented the child from attempting to walk. On August 3d, 1852, the tight
band on the outer side of the foot (represented in fig. 80) was divided by means of
a sharp-pointed bistoury inserted from within outwards; a few fibres of condensed cel¬
lular structure could be felt at the bottom of the wound, which were carefully divided
from without inwards, and the edges of the wound brought together in some degree with
sutures. Water-dressing, together with some simple ointment, soon healed the sore;
during which time the foot was kept fixed in a proper position to counteract the tendency
to recontraction.

“ After cicatrisation was complete, a laced boot, with a small spring on the inner side
of the leg, was worn instead of the splint previously adopted; and the mother tells me
that her child, now two years and a half old, can trot about as well as most of her little
playmates of the same age.

“ The shoe, with its inverting spring, is constantly worn, and the foot is directed to
be bent downwards and inwards three or four times a day, in order to stretch the cica¬
trix; so that up to the present time (now five months since the operation) there is no
appearance of any return of deformity.”

TREATMENT.

201

tion of skin in severe neck and other cicatrices. It may
appear preposterous to redivide parts, the healing of which
(on an extensively burnt surface) the surgeon has patiently
toiled for months to accomplish. But the circumstances
during the difficult cicatrisation of an extensive burn, and
at the expiration of a year or more after the cicatrisa¬
tion, are widely different. The shock experienced by the
system at large at the time of the accident, the exhaustion
from want of repose, from suffering, from symptomatic
fever, from an extensively suppurating surface, have com¬
bined to reduce the reparatory efforts of the economy to
the lowest point, so that cicatrisation often creeps on but
slowly, and the surgeon witnesses almost with satisfaction
his attempts to prevent deformity abortive,—attempts which
his duty led him to adopt, but which, by retarding even
that feeble cicatrising process, threatened renewed or pro¬
longed mischief to the general health. He is justly too
thankful to obtain cicatrisation with deformity of one part,
as the price of restoration to bodily health and activity of
the remaining parts. A year or more later, circumstances
have greatly altered; the deformity may have become aggra¬
vated, but the general health is restored, and the compara¬
tively trifling, painless surgical operation required in section
of one or more bands of cicatrix, to be followed by gradual
or immediate replacement of the part, is not only borne with
facility, but is justified by the greater restorative and plastic
energy possessed by the constitution. It has been a source of
gratification to find that the same tendency to recontraction
is not manifested.as immediately after and during the original
healing. In the first instance, the necessary disuse of the
part permitted an easy conquest to the cicatrising and con¬
tracting force; in the second instance, experience has de¬
monstrated that use of the part is an effectual opponent to
relapse.]

LECTURE XII.

Rachitic distortions—Rickets in general^-Causes of; influence of un¬
suitable diet—May affect not only bones, but every tissue in every part
—Genu valgum, or knock-knee, from rachitis, from excessive standing
— Treatment, medicinal, dietetic, mechanical, operative ,

Rachitic Distortions.

W E proceed to consider the third class of acquired defor¬
mities (p. 11); namely, those serious deviations from the
normal form which are peculiar to rachitis or rickets, and
those less considerable distortions which are regarded as
incidental to a debilitated condition of the system. It is
not my intention thoroughly to discuss the pathology of
rachitis, but only so much of the subject as will enable you
to understand the mode of production of the deformity
and the indications of treatment. The important cha¬
racter of rickets is that of softening the framework of the
system; hence a collapse of certain parts, a sinking of
others beneath the superincumbent weight, and a liability
to alteration from the natural shape through the action of
the muscles attached to them. I include in this category
the deformities supposed to arise from debility, as this
condition of system is in some of its effects allied to rachitis.
Certain deformities that are supposed to arise from im¬
proper attitudes and vicious positions of the limbs may,
with equal propriety, be here considered.

Numerous infants, born perfectly sound, about the
period of dentition, or that of weaning, suffer from gastro¬
intestinal derangement, and, in spite of abundance of food,
become debilitated, and at the period when children usu¬
ally attempt to walk are observed to make no use of their

CAUSES OF RACHITIS.

203

limbs. In these cases the effect of the gastro-intestinal
disturbance is to impair the digestion and assimilation of
food, the maintenance of the structure, and the growth of
the several parts of the animal economy.

Many infants, equally robust at birth, become de¬
bilitated as their age increases in consequence of the
poorness of the milk received from the parent, produced
either by derangement of health, through luxurious and
enfeebling habits, and perhaps through constitutional de¬
bility, as among the rich, or induced by insufficient food
and other causes, as amongst thousands of the poorer
mothers of this metropolis. Whatever be the remote cause
of the debility in question, the proximate cause, imperfect
assimilation of food and impaired nutrition of the frame, is
the same. This form of debility may reach so considerable
a degree as to constitute a true cachexy. It is not my
purpose to enter into a detailed consideration of the opin¬
ions entertained respecting the mode of operation of the
causes of rachitis compared with the influence of the same
causes in the production of tuberculous and other cachexias.
I may, however, remark, that an interesting field for re¬
search is offered by rachitis to the organic chemists ; and
it is not improbable that we are approaching (1843) the
discovery of the true nature of the deterioration that the
blood undergoes in this disease,*

* Since the delivery of the above lecture the author was shewn by M. Gue¬
rin, at Paris (in 1844), a series of preparations and drawings intended for
the illustration of an elaborate and valuable work about to he published on
this subject. M. Guerin has artificially induced rachitism in domestic animals,
by subjecting them to the influence of an unsuitable diet; and has arrived at
the conclusion, that rachitis results from improper food, tubercular disease
from insufficiency. This opinion is very plausible; and if correct, is cal¬
culated to lead to improvement in the management of infants, and preven¬
tion of rachitis. In the absence of the detailed reasons on which M. Guerin’s
opinion is founded, it may still be asked, whether improper food does not
act in the manner described in the above lecture, by disturbing the digestive
functions, and inducing results identical with those of insufficient nourish¬
ment ?

204

RACHITIC DEFORMITIES.

[Casual observation upon domestic animals has shewn
the author that rachitis is a common disease in the young of
the canine race when fed upon farinaceous instead of animal
food, and that prompt improvement occurs when the diet
is changed from biscuits to meat. A large proportion of
infants in this metropolis are reared upon a scanty animal
milk-diet from the mother’s breast,—the remaining food
requisite to satisfy the child’s .hunger being furnished from
the vegetable kingdom, i. e. the various farinacea. The
order of dentition — the early development of incisors in
infants — indicates a greater adaptation to animal than to
vegetable diet. Observation of the diseases of children,
and of the beneficial effects of animal diet, confirms what
comparative physiology suggests.

The fear of mixing “ the two milks” during infancy,
and the fear of grossness during childhood from animal
diet, deter not only the ignorant, but sometimes highly
educated mothers, from following the impulses of nature
in giving to the young plain and wholesome articles of
diet, of which they would readily partake. The author’s
opportunities of observation of infants and children, in
public charities and in private practice, has convinced him
that from the operation of the above fears thousands of
children are annually starved into rickets, either into
the rarer severe forms of the disease (universal rachitis),
or the numerous slighter manifestations of it (" weak
ankles,” “ weak knees,” “ pigeon-breastedness”). The
author may be permitted to state that even many medical
men are influenced by these fears; and in the case of
infants, when “ artificial” food is compulsory, advise a
largely watered milk or milked water, when they should
recommend a food containing as great a proportion of
animal nutritive matter to the containing water as human
milk does.

The younger the infant which is deprived of the breast,
the less is the aptitude to digest and assimilate farinaceous

CAUSES.

205

substances ; and tbe greater is tbe necessity for an amply
sufficient supply of slightly diluted pure unskimmed milk
of a domestic animal.

The extent to which insufficient nutrition and rachitis
is sometimes met with, even amongst wealthy families,
illustrates the danger of too-ready abandonment of the
maternal instinct in the management of children, and the
substitution for it of a little book-learning. The author
has been consulted in families in which, for an extreme
example, there were five or six rapidly growing daughters
denied the use of meat more than twice a week, entirely
debarred the use of salt or of wholesome fruits, even
restricted in the quantity of bread; all in consequence of
morbid anxiety to cultivate temperance in food, to avoid
grossness and apprehended stomach-ailments.

The author’s attention has been directed to such in¬
stances of mismanagement by every child in the family
having presented some signs of rachitis. In the rearing
of children it should never be forgotten, that the tolerance
even of excess in them is very great, provided they have
abundance of air and exercise. The evils of excess are
spontaneously counteracted in childhood by several of na¬
ture’s efforts for that purpose, e. g. the easy regurgitations
in an over-fed infant, and the comparative habitual loose¬
ness of bowels in early life : but the evils of under nutri¬
tion are not so promptly discovered; they are often latent
(to the inexperienced eye), often insidiously progress until
a cachexia, rachitis, or tuberculosis manifests itself. It is
scarcely necessary to add, that amongst the remote causes
of rachitis, as of disease in general, impurity of air, ex¬
cessive humidity, uncleanliness, hereditary predisposition,
other diseases, &c. should be enumerated.]

Now, although we do not understand the intimate
nature of the disorder of assimilation, it has long been
known that in rachitis the osseous system undergoes a
series of morbid changes, characterised, in the first in¬
stance, by deficiency of calcareous matter, hence dimi-

£06

RACHITIC DEFORMITIES.

nislied firmness,. This is ultimately succeeded by mor¬
bidly increased calcareous deposit, unnatural density and
bulk, with the conditions technically denominated ehurna-
tion. If rachitism occur so early in infantile life that the
bones have never become perfectly ossified, an arrest of
their development may be said to have taken place; but if
it occur at a later period, removal of the calcareous matter
already deposited is supposed to ensue, and the bones un¬
dergo softening. In the great majority of instances—per¬
haps in every instance — the rachitism consists in arrested
development. I do not remember having witnessed a case
that has satisfactorily been proved to have originated sub¬
sequently to complete ossification.

Rachitism is not solely a disease of the osseous system,
but its effects are in this part more obvious, and therefore
have been longer noticed. My own opinion is, that every
tissue of the frame is involved in the loss of tone and firm¬
ness,—the bones, ligaments, the involuntary and voluntary
muscles and their appendages, the membranes, the glan¬
dular organs. We cannot doubt the evidence of our senses
respecting the organs within reach of sight and tact; and
should we not anticipate that those more remotely situated
—the nervous system, for example—are similarly affected ?
In truth, we may regard the greater number of cases of
chronic hydrocephalus* as manifestations of rachitis. We
possess the solution of the reason of the universality of
rachitism in the deterioration and the poverty of the blood
in some of the ingredients essential to the proper growth,
of the frame. I would willingly dwell a few moments
longer on this topic, as I conceive the attentive watching
of the early stage of rachitism, the precursory signs of
rachitic deformities, especially important to the medical
practitioner. The treatment of rachitic deformities is a
successful department of orthopaedy; but you will be better
satisfied if, on the appearance' of the precursory signs, you
should be enabled to prevent deformity.

* Hereditary predisposition to cerebral disease having pre-existed.

CAUSES.

207

Rachitic deformities rarely become the subject of at¬
tention before the child attains the age of [fifteen or]
twenty months or two years, and sometimes you will not
he consulted until much later; whereas the precursory signs,
consisting of slightly enlarged head, weakness of the hack,
pallid face, flabby though bulky limbs, tardy dentition,
tumid abdomen, with continued slight derangement of the
stomach or bowels, manifest themselves from the sixth to
the twelfth month. Soon the wrists begin to enlarge, the
ribs to flatten, the abdomen becomes protuberant, the tibiae
become curved, and the ehild remains incapable of standing.
This is the second stage of rachitis, in which deformity is
already apparent. In the next stage more numerous arti¬
culations become distorted ; the inner ankles sink beneath
the weight of the body, the curvature of the leg-bones in¬
creases, the knees project inwardly and “ knock together,”
the thigh-bones curve forwardly, flexion of the pelvis upon
the thighs, and lordosis or curvature forwards of the lumbar
vertebras, ensue.

The disproportion between the hulk of the abdomen
and the thorax now reaches its maximum; the first is
double or treble the natural size, the thorax exceedingly
small, the sides of the chest fiat, or even greatly indented.
The sternum is often projected forwards, or its lower ex¬
tremity with the cartilages of the left ribs elevated, marking
the unwillingness of the heart to hear compression. Indeed,
the pulsations of this organ are often visible over a large
extent of surface. In extreme cases the clavicles, the'
humeri, and the bones of the fore-arm, are curved to a
considerable extent. The upper portion of the vertebral
column often suffers; hut this subject shall be deferred until
the lecture on spinal curvatures. It is not surprising that
with this amount of impeded development and deformity,
the stature of the individual should be very diminutive.
Here are drawings of the entire frame of rachitic individuals
at several ages, in which you perceive the various distortions
I have enumerated. One, for example, fig. 83, of an indi-

208

RACHITIC DEFORMITIES.

vidual nineteen years of age, less than four feet in height;
and another (fig. 84), of a boy aged eight years, thirty
inches only, the head alone forming nearly a fourth part
of the height.*

The distortions of the upper extremity do not se-

Fig. 84.

Outward curvature of thigh and General rachitic deformity. The disproportion-

leg bones, and consequent flat- ately large 'development of some parts and

feet. arrested development of others is conspicuous.

riously affect the functions of those parts, and there¬
fore seldom merit any special treatment. The most fre¬
quent rachitic deformity of the lower extremity, and that
which more frequently attracts attention, is that popu¬
larly denominated knock-knees, in-knees, and described
by professional writers under the name of genua valga.

* See a most valuable paper in Medico-Chir. Transactions, “ On the
effects of rickets upon the growth of the skull,” vol. xxvi. 1843, by Mr.
Alexander Shaw, surgeon to the Middlesex Hospital.

GENU VALGUM.

209

The various models before you will illustrate the nu¬
merous grades of this affection, which consists, as the
popular designation implies, of an inward inclination of
the knees. A single knee may be slightly affected, or
the deformity of one knee may reach an extreme degree,
the leg being everted almost to a right angle with the thigh,
the opposite member remaining straight; or when both
knees are affected, one of them (usually the left) is more
severely distorted than the other, as in this model (fig. 85).

Fig. 85.

210

GENU VALGUM t CURVATURE OF BONES.

that it ceases to attract attention, or the limb entirely
recovers. It is, however, often considered to he cured,
when an attentive examination demonstrates the traces of
its existence. When neglected, the deformity increases

Fig. 8G.

gradually, difficulty in locomotion is experienced, and it
often becomes in time impossible. I have been consulted
concerning many patients with the highest grade of this
affection, in whose early infancy their parents were as¬
sured the “ weakness” and deformity would spontaneously
subside, that the children “ would grow out of it.” I
advise you not implicitly to trust to nature in these cases.
When once the straight line of the limbs is to any con¬
siderable extent destroyed by this inward inclination of

ANATOMY OF GENU VALGUM.

211

the knees, the assistance of art is imperatively required
for its relief. The affection commences by relaxation of
the ligaments and muscles surrounding the articulation
the inside of the knee is less protected than the outer side,
hence an inward yielding. This is accompanied either
with almost imperceptible curvature of the leg-hones, or
with extreme curvature, as in this model (fig. 86), and
often with inward inclination
of the ankle. The internal
condyle of the femur becomes
very prominent, and some¬
times disproportionately en¬
larged, whilst the develop¬
ment of the external condyle
is impeded.

[The only special anatomi¬
cal illustration of Genu val¬
gum the author has met with
is contained in Sandifort’s
Museum Anatomicum, vol. iv.

Plate 29.* It represents (fig.

87) the characteristic inver¬
sion of the knee, the dispro¬
portionate development of in¬
ternal condyle, or rather the
atrophy of the external one,
the disappearance of articulat¬
ing surface on the front of con¬
dyles consequent upon disuse,

* [Sandifort attributes this example of Genu valgum to hydrops articuli,
from which the softening and subsequent hardening of the bones may possibly
have proceeded ; but his description corresponds with advanced rachitic Genu
valgum. He says, “ Forma nimirum ossium, ubi articuiationem componunt,
maxime est mutata; seque ac si hsec ossium extrema in prima morbi periodo,
quando emollita fuisse videntur, graviditate corporis compressa, preetema-
turalem hanc acquisiverint figuram, quam dein, duritie ossis rursus aucta,
retinuerint, dum post illud tempus marginum superficierum articularium ex-
creseentias procul dubio exortse sunt.”]

Fig. 87.

Arrangement of hones in Genu valgum.

212

TREATMENT OP

—habitual flexion of the knee (as in severe cases) having
been combined with the inversion. The part formerly
occupied by articulating surface is thickened and everted
from osseous deposit. The articulating surfaces of the
tibia were much degenerated and inclined backwards, espe¬
cially the external one, causing a kind of sub-luxation.]

The head of the tibia also appears unusually large.
Sometimes its internal surface is merely prominent; at
other times, a remarkable projection, quite angular, like
that of a badly united fracture of the tibia, is observed two
or three inches beneath the internal and upper edge of this
bone. After considerable duration of the deformity, cer¬
tain fibrous tissues on the external or concave side of the
joint become contracted and undergo structural shortening.
These tissues consist principally of the biceps, the attach¬
ment of the vastus externus to the head of the tibia, and
the external lateral ligaments of the knee.

A deformity similar in form (fig. 88) is frequently
witnessed in youths who have been too early employed at
occupations requiring much standing or walking, as in shop
and errand boys, printers, smiths, &c. Constant standing
in one position is more prejudicial than even undue walk¬
ing. Occasionally it arises from, or rather it is first no¬
ticed after, a sprain, a fall, or other accidental injury of
the knee. Genu valgum may coexist with every other
rachitic deformity. Both knees sometimes incline in the
opposite direction (fig. 92), or Genu valgum may exist,
which by its pressure against the opposite knee, occasions
an outward yielding of the member.

Treatment .—General medicinal and dietetic treatment
is essential in this, as in every rachitic deformity, so long
as the rachitic cachexy exists; but when this constitu¬
tional debility is removed, and the resulting deformity
alone is present, the remedies specially directed to the
removal of the abnormal form are available. These mostly
consist of mechanical instruments; and occasionally teno¬
tomy may be serviceable.

GENU VALGUM.

213

In the treatment of the incipient stage of this affection
there are, therefore, three indications to be held in view:

Fig. 88.

Genua valga produced by excessive standing during adolescence.

1. the cure of the constitutional derangement; 2. the re¬
moval of the superincumbent weight of the body, which
tends to increase the deformity; and 3. the straightening
of that already existing.

The first indication may be effected by administration of
preparations of iron and iodine [ol. morrhuse], removal to a
purer atmosphere, country air, or the seaside, by greatly
restricting the child in the quantity of fluids drunk, by en¬
couraging the use of animal food. Rachitic children, or
those not actually rachitic, but weakly, usually take much
fluid, and are very averse’ to animal food. Sometimes a mo-

214

RACHITIC FLATTENING OF RIBS.

derate allowance of wine and water, or of diluted malt
liquor, may be recommended. Occasionally gentle laxa¬
tives may be needed. The ponderous abdomen may. be
much lessened, and the functions of the alimentary canal
much benefited, by a proper bandage. The support thus
given to the abdomen prevents the great distension of the
alimentary tube, and. enables the child better to maintain
an erect position. It is further useful by limiting ab¬
dominal and exciting thoracic respiration; a circumstance
of importance, by its contributing to removal of the flat¬
tening of the ribs.*

The second indication may be fulfilled either by the
child not being permitted to endeavour to walk, or by
affording mechanical support for the purpose of facilitating
exercise.f When the tendency to deformity is considerable,
and the child very young, or confirmed rachitis exists, the
general debility is so great, that you may advantageously
recommend that the erect posture be not for a moment
permitted, notwithstanding that the child instinctively en¬
deavours to support itself. The child may be constrained
to amuse itself on the floor. Carriage-exercise in the
open air should be resorted to as often as the weather
may permit. But after infancy the difficulty of restrain¬
ing a child from attempting to walk becomes insuper-

* The transverse diameter of chest is sometimes reduced to one-fourth.
When the flattening of the ribs has been considerable, the author has been
accustomed to recommend, with advantage, simultaneous exercise of both
arms of the little patient in pulling a couple of lines working over pulleys,
with small weights attached (a many-coloured doll, or other toy, for example).
Each line and pulley should be fastened at opposite ends of the apartment,
in order that both pectoral and serratus muscles of the child, sitting on the
floor in the middle of the room, should be equally excited into activity. Fre¬
quent compression of the chest, with the hands of a competent person, in the
antero-posterior direction is useful. Jalade-Lafonde ( Recherch.es •pratiques
.. sur les principals Difformites, deuxieme partie, p. 164, Paris, 1829,) recom¬
mends this to be done at the dose of expiration, in order to necessitate lateral
expansion during the succeeding inspiration. See also Dupuytren “ On
lateral Depression of the Walls of the Chest,” Sydenham Soc. 1847, p. 383.

. f See Lecture on Spinal Curvature.

TREATMENT OF GENU VALGUM.

215

able; the rachitic cachexy is prohahly diminishing, the
members becoming stronger; still, when erect, a consider¬
able yielding of the joints presents itself. The question
arises, will you still prevent this child from taking exercise ?
Observation teaches that if the knees yield from the straight
line the deformity tends to increase, and that before the
rachitism will have completely subsided, before the bones,
ligaments, and muscles will have acquired the natural
strength, structural shortening of certain structures on the
outer side of the articulation will have ensued; in fact,
that before the time the constitutional disorder is at an
end, the deformity will have become confirmed. Exercise
in the open air is so important a means of improving the
general health of these patients, that the propriety of adapt¬
ing mechanical support to the limbs, and thus enabling the
child to profit by the air, will suggest itself to you. You
must weigh the advantages and disadvantages of mechanical
support. My experience enables me to affirm, that the
benefit of proper mechanical support is so considerable, that
you should unhesitatingly have recourse to it at this stage
of the disorder. No one would approve of encasing the
limbs of a healthy • child in irons, any more than of the
administration of mercury or arsenic to persons in good
health; but in neglected genua valga of a certain severity,
the increase of the deformity is certain, and more often
mechanical means will afterwards be required, when they
can no longer so effectually assist.*

The third indication, that of removing any contraction
and structural shortening, or permanent deformity, should
be accomplished by bandaging common straight splints on
the outside of the knees; these should be worn night and
day, and removed at certain times for the sake of cleanli-

* When projection of abdomen and hollowness of loins exist, it is impor¬
tant that the irons or splints should be connected by a band extending behind
the pelvis, by means of which a comparatively upright attitude is at once
obtained.

216

RE-ADAPTATION OF

ness, for the use of frictions with manipulations directed
to the maintenance of a flexible state of the articulations,
otherwise the joints will become rigid, and much pain be
produced in the restoration of mobility. In severe cases
common splints will not suffice ; you should then use irons
attached to shoes.*

* Irons are only effective in the treatment of severe Genu valgum when
they are constructed without movements opposite the knee-joint. The pre¬
judice against splints or irons has so greatly declined since the above was
written, that in the present day, 1853, it appears unnecessary to dilate upon
the advantages of mechanical treatment of these deformities.

The following case will illustrate the difficulties attendant upon successful
treatment after adult age of severe Genua valga complicated with other de¬
formity :

“ Case of complete inability to walk for many years from contraction
and inward inclination of both knees, with distortion of the Jeet resembling
Talipes varus. Treatment mechanical.

“ August 1839. Miss ***, set. 21, stated to have been unable to walk
since five years of age. On inquiry, ascertained that a weakness of the knees
had existed from earliest infancy, and had increased until locomotion became
altogether impossible. Subsequently a distortion of the spine is reported to
have occurred; for which she has been seven years under treatment in the
constantly recumbent position by a well-known spinal physician. The lame¬
ness is so considerable that, even when supported by two assistants, the
patient is unable to make a single step. This utter helplessness as regards
locomotion arises more from distortion of the knees than of the feet, although
the position of the latter corresponds with non-congenital Talipes varus. The
foot-deformity appears to have been induced solely by long-continued disuse
of the limbs, and consequent preponderant action of the muscles on the poste¬
rior and internal aspects of the limbs. No evidence of its dependence upon
spinal disease exists.

“ In the recumbent posture the appearance of the limbs corresponds with
fig. 85 ; but on the attempt to stand, the knees are not only thus greatly
inverted, but are much bent; the thighs at the same time being flexed
on the pelvis, and the lumbar region much hollowed. The stature of the
patient is, in consequence of these flexures, diminished. Little voluntary
power in the muscular structures of the lower extremities exists, even in
the recumbent posture. During extension of the knees the ankles diverge
as before described, but on raising the knees towards the abdomen the ankles
approximate. Tension of the tendons of the biceps of the fascia lata and
external lateral ligaments of the knee, constitutes the more prominent cause
which maintains the distortion of the knees.

“ Ike friends of this young lady having objections to any operation,

ARTICULAR SURFACES.

217

I have mentioned that this deformity occasionally oc¬
curs in adolescence, and cases present themselves that have
existed since infancy. The shortening and rigidity of the
tissues on the outer side of the knee are often so unyielding,
that you may ineffectually devote months to the mechanical
treatment (see note, p. 220). In these cases you may accele¬
rate the cure by subcutaneous section of the biceps tendon,
the inferior termination of the vastus externus, and the
hands of fascia in this situation. A great improvement
speedily succeeds the operation. After cicatrisation the
mechanical treatment should be pursued with the same
diligence as necessary without the operation. In a few
weeks all resistance to straightening will he removed.

the treatment was undertaken by mechanical means. At the expiration of
three months the inversion of knees was overcome so long as they remained
extended, but when flexion was attempted a tendency to recurrence of the
eversion of the legs became evident. Six weeks later, the resistance offered
to the replacement of the feet by the gastrocnemii and adductors was suffi¬
ciently overcome to permit the wearing of steel supports, in which exercise
might be attempted. Many years having been passed in the recumbent pos¬
ture, the circulation of the blood had become adapted to that position of the
body only; great debility of the whole muscular system existed, and the pa¬
tient, so long accustomed to one position, shrank with more than common
timidity and nervousness from the attempt to stand upright. The necessity
of caution was anticipated; but notwithstanding the utmost attention, the
previous administration of wine to support the action of the heart under the
increased labour devolving on it during the erect position of the frame, vertigo
and syncope attended the first effort. Many days elapsed before the patient,
even with the assistance of friends or crutches, could support herself upright
and attempt to make a step; but before the expiration of six months from
the commencement of the treatment, I had the pleasure of witnessing so great
an amendment, that my patient could with slight support stand erect, placing
the entire soles on the ground, and even walk a few paces. With the aid of
crutches, locomotion about the house and garden was effected for the first
time since early childhood.

“ At the expiration of eighteen months she laid aside the cumbrous irons
at first indispensable ; and wearing a slight support to each knee, the use of
which had been recommended as a precautionary measure for some time longer,
she is able to walk without lameness a distance of two or three miles.

“ Two years afterwards this patient visited me, wearing a lace-stocking at
the knees on account of the uncommon laxity of the joints, and tendency of

218

GENU VALGUM : TREATMENT.

Mechanical support is required for one or two years after¬
wards, until the articular surfaces have become adapted to
the change in their relation, and until the debilitated
muscles have acquired strength.*

some degree of Genu valgum to become permanent. On examination I per¬
ceived that perfect adaptation of the articular surfaces of
the knees to the altered form of the limbs had not yet oc¬
curred ; for, supposing the annexed diagram, a b, to repre¬
sent the relation of the (right) thigh and leg before the treat¬
ment was commenced, the relation of the leg to the thigh
immediately after the Genu valgum was overcome was that
represented by the dotted portion of the diagram.

“ From this diagram it appears, that before the treatment
the part corresponding to the internal condyle only im¬
pinged upon the internal portion of the articular surface
of tibia, the remaining part of the articulating surface of
the femur having been separated from the tibia by a trian¬
gular space. In the act of walking, therefore, unsupported
by instruments, a continual tendency to relapse into the
old position existed. Compare fig. 87, which relates to
opposite leg. It was at that period an interesting question, whether, as the
patient had reached puberty, the articular surfaces of the femur and tibia
would adapt themselves to their altered relation. Confiding in the extraor¬
dinary powers of adaptation manifested by articular surfaces as after treat¬
ment of severe club-foot, I trusted, that although the growth of the body was
completed, this beneficial result would in time take place, if the position of
the legs in the perpendicular axis of the limbs could by mechanical aid he
preserved. This result did occur. For several years afterwards I received
an occasional visit from this patient. She ultimately lost all trace of Genu
valgum and of undue laxity of articulations.

“ So great had been the laxity of the integuments and ligaments over the
internal part of the knee-joints, that I had recourse to the expedient of an
artificial contraction in those situations by producing a large eschar by means
of Potassa fusa oyer the inside of each articulation. The superfluous skin
was thus removed; and as the eschar was deep, the subsequent shrinking of
the cicatrix in the integuments and areolar tissue assisted to maintain the
articulations in their natural positions.

“ It is unnecessary to add, that this treatment by eschar was solely sug¬
gested by the severity of the case, and the necessity of extraordinary measures
after adult period of life was attained. It is not recommended for imitation
in ordinary Genu valgum .”—Extract from Author's Case-booJc.

* See remarks on Tenotomy in following lecture.

219

LECTURE XIII.

Rachitic distortions continued,—Additional remarks on treatment of Genu
valgum,—Value of tenotomy in Genu valgum considered; use of arti¬
ficial contraction as a means of perfecting a cure—Rachitic curva¬
tures; mode of production, influence of muscular action—Rachitic
deformity of foot; rachitic valgus—Treatment of curvatures of lower
extremity — Flat-foot, or spurious valgus — Treatment.

The former lecture contained some general remarks on
rachitis, and the special consideration of Genu valgum, or
in-knee. If the description of this deformity be borne
in mind, the reasons for considering the changes of form
resulting from rachitis as a separate order of non-conge-
nital deformities will be comprehended. The contractions
arising primarily from diseases and injuries of articulations
were included under the head of ankylosis ; the distortions
dependent on primary disturbance of the muscular system
constituted contractures ; whilst those which at present en¬
gage our attention arise from causes which simultaneously
affect the parts composing the articulations and the mus¬
cular structures which move them.

The model (fig. 85) which I selected at the last lecture
for the illustration of Genu valgum represents the defor¬
mity at an advanced stage. It exhibits the constant state
of the individual from whose limbs it was taken,— recum¬
bent or standing, the deviation of the limb from the na¬
tural form remained the same,—temporary pressure effected
no amendment in position. But in order that the affection
in the less severe form may as readily be recognised, I
shall direct attention to this series of models from young
children, whose ages varied from twenty months to three
or four years (fig. 89 represents one of the series in ques¬
tion). In this instance, for example (fig. 89), the child
was unable completely to walk alone ; when recumbent
no deformity was apparent to the casual observer; but

220 genu valgum: mechanical treatment.

when placed on the feet, or when endeavouring to walk’
the legs became everted. You observe the knees are not

Rachitic distortion, or “ deformity from weakness,’’ in young child: Genua valga.

the only articulations affected; the ankles suffer, the toes
of one foot being everted, those of the other inclined in¬
wardly. Such a case may he rapidly remedied by the
simplest mechanical support, or by interdicting exercise:
the other case (fig. 85) will, especially in adolescents, re¬
quire tenotomy, or the recovery he much facilitated by it.
Notwithstanding the mention of the aid derivable from
tenotomy, do not too hastily have recourse to operation.
I have frequently succeeded in the restoration of adults by
the mechanical means in daily use in this institution. The
question whether, in a given case, tenotomy shall be em¬
ployed, becomes one of duration of treatment.*

* For some years past the author has wholly discontinued the use of
operation in Genu valgum, having ascertained by comparison of the time
occupied in treatment with and without operation, that, although with the

IS TENOTOMY NECESSARY?

After complete straightening of severe Genu valgum, a
superabundance of tissues on the internal side of the knee
may exist. The skin and subjacent structures appear loose,
and favour the tendency to relapse. This disproportion
does not long continue in children, as from the growth of
the limbs the natural relation becomes established. But
in adolescents and adults who have respectively nearly or
wholly completed their growth, its removal is more slow and
uncertain ; hence a longer continuance of weakness.*

Rachitism and cretinism are sometimes associated, but
they are by no means necessarily combined. On the con¬
trary, rachitis is often accompanied with precocity of in¬
tellect ; but when the brain especially suffers from rachitis,
the similarity with cretinism is very great [if they are not
pathologically identical].

Rickety distortions of the hones are very common.
Rachitis first displays itself by enlargement of the epi¬
physes of the long hones, the inferior extremities of the
radius and ulna being peculiarly predisposed to suffer in
this manner. When the disease is more severe, curvatures
ensue. The long bones present indications of curvature in
the following order: the ribs, tibia and fibula, femur, radius

operation a rapid improvement is at first visible, the ultimate result is the
same whether or no the operation be performed. In no other than adults did
the operation ever appear justifiable. The length of time requisite for obtain-
ment of adjustment of articular surfaces of the femur and tibia in severe adult
cases, renders the gain in the first instance by operation of little moment.
The author has found the inversion yield in the severest cases within three
months to improved mechanical treatment, consisting either of wooden splints,
hinged at outside of knee, and straightened by a ratchet or male and female
screw, or with a strong common stiff iron attached to a shoe, properly adapted,
and duly removed for Motion and manipulations (p. 26). At present the
author does not even find it necessary to confine such severe cases to the
recumbent position during the daytime. He has treated, with the aid of
irons, many adolescents who have followed sedentary occupations during the
whole period they were under observation. Habitual voluntary flexion of the
knee should not in these cases be permitted until many months after the
inversion has been overcome.

* See case, note, p. 216.

MODE OF PRODUCTION OF

and ulna, humerus and clavicle. Being softer than natural,
they yield to the action of the muscles inserted into them.
This is particularly evident in the frequency of change of
form of the ribs. The natural office of these bones is to
maintain the capacity of the thorax. When their elasticity
and firmness is destroyed, the thorax is compressed between
the antagonist inspiratory and expiratory muscles, and
flattening with diminution of capacity results. The ribs,
notwithstanding that they have no superincumbent weight
to support, yield as early, and often earlier, than any other
long bones. The ulna and radius support no superincum¬
bent weight, yet they are liable to curvature, and fre¬
quently suffer to a considerable extent.

If, in the case of the radius and ulna, we cannot admit
the influence of superincumbent weight in inducing cur¬
vature, we are compelled to search for another cause. If
we assume this cause to consist of muscular action, it should
follow that as these bones are covered with muscles on
their anterior and posterior surfaces, the bones will yield
in the direction of the stronger set of muscles. The an-'
terior muscles of the fore-arm, the flexors and pronators,
constitute the more powerful mass, hence they tend to ap¬
proximate the upper and lower extremities of the ulna and
radius, causing an anterior concavity and a posterior con¬
vexity of these bones. I have never witnessed an anterior
convexity of them. In the lower extremities the influence
of superincumbent weight cannot be rejected; but if cur¬
vatures in this situation wholly depended on this cause,
no pathological explanation seems probable why curva¬
tures should not readily occur in every direction.* Obser¬
vation, however, shews that curvatures of the femur, tibia,

* Delpech, who stands pre-eminent amoDgst the French as a scientific
cultivator of orthopaedy, had rightly appreciated the influence of muscular
action in production of rachitic curvatures. “ II faut examiner avec atten¬
tion le squelette d’un rachitique, pour concevoir comment les inflexions les
plus bizarres en apparence, et qui cependant sont symetriques des deux
cotes, sont produites par Faction musculaire.” Observations cliniques de
Delpech et Trinquier, p. 236, Palis, 1833.

RACHITIC CURVATURES.

and fibula, occur forwardly and outwardly (as in these
models, fig. 90), sometimes principally forwards. This is

Rachitic curvature of the leg-hones, with rachitic T. valgus.

explicable by the fact, that the more powerful mass of the
muscles is situated on the posterior and internal aspects of
the members. The origin of curvatures from muscular
action affords a solution of the occurrence of curvatures
in children who have never been placed on the feet, or
who have never attempted to walk.

The next feature of rachitic curvatures to which I shall
advert is that which accords with the law I have, early in
these lectures, laid down, that wherever the origin and
insertion of a muscle remain, for a period of weeks or
months, approximated, [proportionate] structural shorten¬
ing of its fibres will ensue. The muscles, therefore, on
the concave side of the member become contracted, and
constitute a principal obstacle to restoration of the form

224 < OUTWARD CURVATURE OF ENTIRE EXTREMITY.

of the limb. You will observe in these curvatures (see
fig. 90), that the articulation of the ankle suffers from the

Fig. 91 .

Rachitic curvatures in a
young infant before walk¬
ing was attempted.*

Rachitic curvatures in a child
commenced before walking was
attempted, much aggravated in
right foot by locomotion.

altered direction of the shaft of the tibia, the internal mal¬
leolus c being prominent, the toes become everted e, an un¬
due strain of the ligaments and muscles of the sole takes
place, and a flat-foot, or rachitic valgus, is produced,—this
ankle-deformity, if not remedied, becoming, in later life,
often the chief impediment to ease and comfort in walking.

Treatment of Curvatures .—The available means for
promoting improvement of the form of the thorax have
been already mentioned, and it is unnecessary to dwell on
curvatures of the upper extremity.f

* A very unsightly gait is induced by external curvature of thigh and leg
hones ; for whilst the weight of the body is being thrown from one limb to
the other, the trunk necessarily inclines greatly to the limb which is in the
act of being raised, progression taking place by a continued lateral balancing,
soon followed by fatigue. Jalade-Lafond, Recherch.es pratiques sur les prin-
cipales Difformites, deuxieme partie, p. 279. Paris, 1829.

f Rachitic curvatures of these parts are often mistaken by suspicious
parents for neglected fractures. They sometimes doubtless have been aggra¬
vated by accidental injuries, as by rough handling of a hasty nurse.

Hippocrates (Mochlicus) alludes to “ distortions when the bones are
crooked.” Sydenham Soc. edit. p. 680.

CURVATURE OF BONES.

225

The treatment of curvatures of the lower extremity may
therefore engage our attention. It is, in the first place,
essential to determine the possibility of a rachitic bone be¬
coming straight under any circumstances. This is proved
by observation of the spontaneous restoration which occurs
in slight cases. An additional proof is afforded by the
straightening of more severe cases by art. In slight cases
you may adopt the general principles of treatment of rickets
described in the last lecture, and safely leave the curvature
to the spontaneous efforts of nature. Do not, however,
trust her too implicitly. When with advancing age the
deformity increases, the propriety of resorting to mecha¬
nical support should be considered. Common straight
splints, bandaged on the concave side of the member, or
irons properly adapted by the instrument-maker, should
be employed for this purpose. I repeat the expression
‘properly adapted for if the person you employ manufac¬
tures “irons” without reference to the individual case, the
straightening may not be accomplished, and your prescrip¬
tion be pronounced useless, if not injudicious. Cases fre¬
quently present themselves in which the question will arise,
whether the period for effecting straightening has not already
elapsed. You will judge, from the general condition of the
individual, whether the necessary deposit of calcareous mat¬
ters, and consequent normal firmness of the bones, or even
eburnation, have taken place, and whether the ligaments

Duval (Aperfu sur les principals Differ mites, Paris, 1833) remarks
that Genu valgum arises through weakness, and the desire of increasing the
basis of support.

Genu valgum is a very common deformity, whilst outward curvature of
the knee is comparatively unfrequent. Genu valgum may be regarded as an
exaggeration of the normal state, for the femur naturally presents obliquely
inwards, causing the habitual projection of the internal condyle, and the
ordinary prominence of the inside of the knee. See statistics for eight years
of Royal Orthopaedic Hospital, at p. 10. Of 7533 patients, 1843 were affected
with Genu valgum. Messrs. Chance and Stevens, of the City Orthopaedic
Hospital, in their annual report for 1852, amongst 799 patients, announce
247 “ knock-knees.”

226

CURVATURE OF BONES.

and muscles have acquired their natural strength.* You
may form some opinion on this subject by manipulation
of the members, by ascertaining whether the hones con¬
tinue elastic, or whether they feel quite inflexible. In
this examination avoid much pressure, or you may find
the bones yield to an unexpected extent. In short, they
may bend to an acute angle, or a fissure or fracture ensue. *

Is tenotomy available in rachitic curvatures ? If the
existence of structural shortening of muscles on the con¬
cave side of the member, and that this muscular contrac¬
tion is a principal obstacle to restoration when the bones
are still soft, be admitted, tenotomy becomes in principle
applicable to such cases. You would expect by tenotomy
to facilitate the mechanical treatment.

The following is the result of my experience of teno¬
tomy applied to rachitic curvatures. In one case in which
the tibia and fibula appeared firm, the rachitism having sub¬
sided, and eburnation imminent, if not present, I divided the
gastrocnemii, with the view of facilitating replacement by
appropriate apparatus. The result was unfavourable, in¬
asmuch as at the expiration of six months, although the
patient walked and ran freely, the bones were not straighter
than before the operation. In another case, a female,
aged 21, who had suffered from repeated fractures of the
long bones during a period of several years, the cause of
the fractures having probably been “ fragilitas ossium,” a
disease described under a variety of names, and the precise

* The state of the teeth frequently affords indications of the direction in
which rachitis tends. When the disease is severe, they are notoriously deficient
in enamel, and even the bony part of the teeth may be so impaired that they
are prematurely shed. It is certain that the bones in general have recovered
the normal hardness, or have reached the state of eburnation, when the por¬
tion of the teeth nearest to the gum is invested with enamel, whilst the re¬
maining part is discoloured and deficient in this important constituent. It
not unfrequently happens that the alternating phases of rachitis, the fluctua¬
tions in intensity that have occurred in its progress, are denoted by parallel
horizontal ridges of enamel separated by dark-coloured lines of dental matter
uncovered, or only partially covered, with this substance.

DEFORMITY FROM OSTEO-MALACIA.

pathological character of which is not determined, tenotomy
was beneficial. This patient.

r Fid. 93.

on her admission to the Royal
Orthopasdic Institution, pre¬
sented several (rachitic ?) defor¬
mities.* That which especially
related to our present subject
was extreme curvature of the
tibia and fibula (fig. 93). The
bones of one leg were bent to
an angle of 70° or 80°. Al¬
though they felt rigid on mani¬
pulation, they were not entirely
devoid of elasticity. The effect
of this considerable angular
curvature was that of shorten¬
ing the limb five inches. The
general health had during the
preceding two years greatly im¬
proved, and no fracture had
during that time occurred. It
was probable that perfect ossi¬
fication of the bones was im-

Curvatures of all the long bones of the
lower extremities. The deformity of

minent. This consideration in-

right limb was the consequence of
frequent fractures of femur and

duced me to test the advantages
of tenotomy.

leg bones. Drawn in 1842 from model
at Royal Orthopaedic Hospital.

* The diseased state—mollities ossium, osteo-malacia, rachitismus adul-
torum et senilis—is said by Rokitansky (Opus infra cit. p. 177) to occur
principally in the trunk, and to be associated with cancer. Rachitic bones,
or the softened bones of young children, although liable to bend upon the
application of a small amount of force, are not liable to break by muscular
action, as upon turning in bed, as was the case with the subject of fig. 93,
or in the case narrated p. 228. What were then the cases, fig. 93 and that at
p. 228 ? If the restriction as regards age and the part affected laid down
by Rokitansky be adopted, these cases were not osteo-malacia, but ordinary
rachitis. They cannot, however, be considered cases of rachitic softening, as
advanced rachitic disease is not confined to a particular part of the frame, as
it was in these cases to the lower extremities.

TENOTOMY IN CURVATURES.

The tendo-Achillis was accordingly divided $ and after
cicatrisation extension was applied. The apparatus em¬
ployed consisted of a shoe-piece to embrace the foot, and
another piece to encircle the upper part of the femur, and
touch the pelvis as a fixed point. Extension between
the foot and hip was effected by a connecting male and
female screw, and the deformity slowly reduced. The
hones (femur, tibia, and fibula) were elongated so as to
permit the approximation of the foot within two inches
and a half from the ground. The interest of this case
consists in the proof it affords of the possibility of reduc¬
tion of extreme curvatures by the aid of tenotomy.

The applicability of tenotomy in ordinary rachitic cur¬
vatures is a perfectly different consideration. It is un¬
necessary in the great majority of cases, because they can
be successfully treated without its assistance ; and in those
rachitic curvatures which resist mechanical apparatus, the
issue of the operation is so uncertain that its performance
does not appear justifiable. This active remedial measure
is the less indicated in rachitic curvatures, for even when
considerable—-as they usually produce shortening of both
limbs—they do not produce lameness.

[The author has under his observation a young gentle¬
man, aged twelve, both of whose lower extremities were
curved, as in right limb, fig. 93. He seldom passes three
months without some fresh fracture in some part of the
frame. The constitutional malady, therefore, upon which
the fragility of bones depends continues. From its analogy
with the case represented fig. 93, the author confides in
the ultimate improvement of the constitution, and conse¬
quent deposit of additional calcareous matter in the bones.
In the meanwhile the limbs have been easily straightened
and guarded against fracture with common splints, without
tenotomy.

Rachitic curvature is sometimes associated with other
deformity, as at fig. 94 (see also case, p. 216). Occasionally

RACHITIC CURVATURE WITH TALIPES.

229

in young children curvature of leg-bones is produced by
improper application Fig , 94i

of pressure in the %

treatment of other %

foot-deformities.] %

I have already
mentioned that, in If!
rachitis, either in con- ^

sequence of curva- . 1

ture of the leg, or w

independently, the m

ankle-joint may he ||l||y j!

affected. The point ^ #

of the foot is there-

fore directed inward- W

lv or outwardly, con- llllllll 1

stituting respectively 1|||||1| |

rachitic varus and val- |

gus. Rachitic inver- I0|t' I

sion of the foot is less ||||p 4

common, rachitic val- l||jp |

gus very common, |||||| |

You may observe ra- lipP \

chitic equino-varus in lip Wi

this model (fig. 9T). Jp||? w\ v

It may be treated by 'nPft' 111

the means applicable 1|1

to Genu valgum and Ww^■.

In the treatment of
rachitic deformities,

the Value of frictions Slight rachitic curvature of leg-hones, and, Genu valgum
withiodinous embro- co-existing with non-congenital varus.

cations, and manipulations suited to rectification of de¬
formity, should not be overlooked. It may be doubted
whether the local application of iodine is in these cases

TREATMENT OF CURVATURES.

beneficial; but the utility of the frictions and mani¬
pulations is incontestable, and the embrocation, at all
events, subserves the unquestionably useful part of the

Fig. 95.

process. The diligent nurse, the experienced “rubber,’*
of which “profession” numbers are to be found at spas and
watering-places, become here invaluable adjuncts (p. 26).

The deformity of flat-foot is a common affection about
the age of adolescence; you may be consulted respecting
its treatment as early as childhood, but it rarely becomes a
serious deformity until the age of from -fourteen to eighteen
years. It is not often produced later, unless from rheu¬
matism,* and occasionally from long-continued exertion in

* Rheumatism, especially iu the labouring classes, frequently lingers about
the internal malleolus, probably in consequence of the greater susceptibility
of this part to diseased action through excessive use. Even when no par-

FLAT-FOOT.

231

standing and walking. Like the Genu valgum which occurs
in growing youths, flat-foot [sometimes] appears inde¬
pendently of decidedly rachitic symptoms. The effects of
common debility upon the limbs are so similar to those
of rachitis, that pathologically I would propose to consi¬
der them as identical; hut for practical purposes, and in
order to simplify the remarks on the treatment, flat-foot
may be considered as dependent on simple debility.

Fig. 96.

Talipes valgus spurius, or flat-foot.

On examination of one of these models (fig. 96) you
remark the sinking and destruction of the tarsal arch, and
consequent flattening of the sole.* In slighter cases no
particular displacement of the tarsal hone can be demon¬
strated; the deformity then consists of a mere yielding,
through elongation of the ligaments and muscles connecting
the tarsal hones, the metatarsus, and the phalanges. In
severer cases (as in fig. 96) the scaphoid, internal cuneiform,

ticular susceptibility exists, patients during recovery from general rheumatism
experience pain at this part through the strain maintained upon weakened
structures by the superincumbent weight of the body.

* See R. Adams in Dublin Journal, 1840.

232 FLAT-FOOT.

and astragalus, leave their respective positions; the first
two become applied to the ground, and the astragalus un¬
naturally projects. The convexity of the dorsum is lost;
eversion of the toes and actual elongation of the foot
ensues. The mobility of the ankle-j oint may persist dur¬
ing months and years; but with increasing deformity it is
annihilated, proper extension and flexion being rendered
impossible. The equilibrium of the muscles of the ankle-
joint is destroyed, the peronei and anterior muscles of the
foot obtain the preponderance, and the eversion of the foot
becomes ultimately as considerable as in true Talipes valgus.
The preponderating muscles undergo structural shortening,
th@ outer margin pf the foot (and even sometimes the
front of the foot ge¬
nerally) is raised from
the ground, locomo¬
tion being effected to
a considerable extent
on the heel. The gas-
troCnemii then waste,
and the gait becomes
very unsightly.* In
the origin of flat-foot
weakness only is the
subject of complaint;
after a certain time
pain at the inner ankle
and in the sole is ex-
Eactreme Talipes valgus spurius, or flat-foot, seen from perienced, especially
outer side. „ , ,.

after long standing or
walking. This pain may be so considerable as to render
erexcise a cause of great suffering; but after another in¬
terval of time, provided necessity has compelled the indi-

* This will remind the reader of the effect of walking, in distorting the
heel in calcaneus and calcaneo-valgus (p. 158), to which the rachitic deform¬
ity spurious valgus, although so dissimilar in origin, approximates in form.

Fig. 97.

THREE STAGES,

vidual to continue laborious exercise, the tissues of the
sole yield sufficiently to obliterate the arch, and the pain¬
ful tension and consequent pain subside. Exercise in
cases of extreme flat-foot, although accompanied with lame¬
ness, is not so painful as in slighter cases.*

It may facilitate a proper understanding of the rational
treatment of this distortion, if it he considered in three
stages. In the earliest stage you have principally to contend
against undue laxity of the tissues about the inner ankle;
the arch sinks owing to loss of tone in those structures which
should maintain the concavity of the sole. The deltoid
ligament, the ligaments connecting the inferior surfaces of
the tarsal bones, especially the calcaneo-scaphoideum, the
muscles, the tendons of which pass by the internal mal¬
leolus into the sole, are evidently weakened. When the
foot is raised from the ground, especially after a few days’
rest, it may present nothing abnormal; hut when the child
stands, the inner ankle projects, and the toes incline out¬
wardly. This is the stage of the affection commonly known
by the name of (t weak ankle,” “ in-ankle.” You should
not conclude that the remaining textures of the limb are
perfectly strong; for you will remember that in rachitis,
and in general debility, every part of the member in some
degree suffers. The tissues about the inner ankle, and in
the sole, suffer in a greater degree, because their office
being to support the superincumbent weight of the body,
to which they are inadequate* they yield, and become
elongated.

In the second stage the displacement is not transient
during the erect posture only,—for example, as in the first
stage,—but is permanent; deformity is present, the foot
cannot be adducted, the mobility of the ankle is impaired,
the yielding of the tissues of the sole is accompanied with

* The author has been consulted in several cases of spurious valgus at¬
tended with pain at inner ankle, which had been mistaken for, and actively-
treated for, inflammation of ligaments of ankle and sole. Complete inflam¬
mation, L e. with effusion of serum, lymph, or pus, never occurs in such cases.

234

TREATMENT OF

pain, habitual eversion of the toes, and organic shortening
of the peronei and of the extensor longus digitorum.

The third stage 'is characterised by aggravation of the
above symptoms, considerable elevation of the outer margin
and front of foot, immobility of ankle, perfect flatness of
sole, sinking of dorsum, great augmentation of length of
inner edge of the foot, approximation of outer side of os
calcis to inferior malleolus, shortening of anterior tibial
muscle, proportionate relaxation of gastrocnemii.

In the first stage, the individual touches the ground
with the natural tripod of the foot (the heel, the ball of
the great toe, and that of the little toe), and with an undue
proportion of the sole. In the second stage, locomotion is
effected on the heel and internal margin of the foot and
great toe. In the third stage, the patient walks almost
exclusively on the heel.

Treatment of the first stage. The general treatment
available in rachitis or in debility will in this stage be
essential to the success of treatment specially applied to
the foot. This should ’consist in restricting the patient in
the amount of daily exercise ;* in preventing the child from
disproportionately resting on one limb, if one only be
affected, or in prohibiting him from standing to the usual
extent at lessons and amusements. Boots appropriately
strengthened at the sides by the shoemaker, or raised on
the inner edge, sometimes furnished with a piece of cork
adapted to the natural form of the concavity of the sole,
should be recommended. Embrocations or manipulations
directed to the inversion of the foot, and prevention of
shortening of muscles on the outside and front of the ankle,
may be advantageously employed.

In the second stage, an iron or spring, to support the
ankle and invert the foot, may, in addition, be employed.
The question of applicability of tenotomy, which is abso¬
lutely necessary in the third stage, may even in the second

“ Pueruli sedentes ludant.” Tvlayow, Opus infra cit.

FLAT-FOOT.

stage be considered. The object of section of tendons is
to remove the organic or structural shortening of muscles
which is consequent on the altered form and relation of
the ankle-joint. In the second stage subcutaneous section
of the peroneus longus and brevis may be advisable; whilst
in the third stage section of the whole of the peronei,
extensor longus digitorum, extensor proprius pollicis, and
tibialis anticus. will be required to restore the form, mo¬
bility, and function of the ankle.*

After the operation the same principles should be
adopted as in after-treatment of club-foot. The apparatus
which I recommend is that used in treatment of club-foot.
(See treatment of Club-foot.) In its application the se¬
veral parts must, of course, be reversed to effect a contrary
action to that required in club-foot, as in flat-foot depres¬
sion of the toes and inversion are required. No deformity
of the foot is so liable to recur; mechanical support is
therefore indispensable for a period of two or three years
after restoration, or until growth is completed. I need
strongly to insist on this circumstance, and add, that your
ingenuity may often be tested in adaptation of the neces¬
sary support.

[The general health is sometimes so much impaired in
cases of flat-foot in growing girls and boys from the age of
ten to fifteen, and the signs of impaired nutrition from im¬
perfect assimilations so evident, that the author has some¬
times derived much benefit from prescribing entire disuse
of walking for a month or six weeks, carriage or horse
exercise being alone permitted. Under this treatment,
with ample repose of body, good diet, and freedom of the
mind from anxious studies, a great improvement in bodily
strength takes place,—the ankle-joints recover power, the
bones and ligaments grow into proper proportions, and the
deformity is quickly cured.

* Greater attention to mechanical treatment obviates the necessity of
these operations, except, irt- neglected cases in the third stage .

236 CURVATURE OF BONES FROM OTHER CAUSES.

Curvatures of bones occasionally depend upon other
causes than rachitis, and are liable to be mistaken for this
disease. Thus a well-marked case of curvature of bones
of the fore-arm, induced by spastic action with structural
shortening of the flexors and pronators, presented itself to
the author at the Royal Orthopaedic Institution in 1840
(Out-patient Register, No. 239). This case, though rare,
shews that the bones of a young child which would have
been capable of resisting the natural muscular action, may
yield to the abnormally increased tension exercised by spas-
tically contracted muscles. Such a case illustrates Mayow’s*

* Mayow Tractatus duo seorsum editi , quorum •prior agit de Respiratione,
alter de Rachitide, Oxon. 1668 ; and Tractatus quinque, quorum ultimus de
Rachitide, ib. 1674.

Glisson’s elaborate works on rachitis and the resulting deformities are
monuments of industrious and extensive observation. They are clearly the
groundwork of many treatises on this disease which have been published
during the last two centuries. (A Treatise on the Rickets, being a disease
common to Children, published in Latin by Francis Glisson, translated by Nich.
Culpepper, Gent., 1651. Tractatus de Rachitide sive morbo puerili, Fran-
cisci Glissonii, Londini, 1660, editio secunda.) These two works of Glisson
are contained in the admirable library of the Royal College of Surgeons.
The author has been unable to ascertain whether other editions of Glisson’s
works, or a still earlier treatise on rickets by Whistler, are contained in the
Library of the Royal College of Physicians; for, on inquiry at that institu¬
tion, he was informed that its library is not open to Licentiates of the College.

Glisson gives an ingenious explanation, with diagrams, of the manner in
which curvatures of the long bones and of the spine, which he compares with
a long bone, take place. He believed that unequal deposit of bony matter,
and consequent unequal growth of the two sides of a bone, occasioned the
curvature. Mayow confutes Glisson’s theory, and approaches more nearly to
the explanation which the author believes to be the correct one. Mayow says,
“ liceat hypothesin hanc nostrum exemplo illustrare, si arbori tenerse et
crescenti chorda superius et inferius alligetur, ita tamen ut non tendatur ;
nullus dubito, quin arbor dicta crescendo incurvabitur.” Mayow, however,
assumes that the muscles on the concave side of a bone do not properly grow,
instead of regarding the bone to be primarily deficient in firmness, and con¬
sequently acted upon by the contractile muscle. Probably both Glisson and
Mayow derived their anatomical observations of rachitic bones from those
of individuals who had died after eburnation had taken place.

J. L. Petit ( Maladies des Os, 1741, t. ii. p. 545) has the most complete
arrangement of the consecutive causes of curvatures : 1st, the softness of the

OPINIONS OF OLDER WRITERS ON RACHITIS.

theory of the production of rachitic curvatures. He be¬
lieved that the curvatures result from insufficient growth
of the muscles, which, by remaining too short, bend the
hones, as a bow is bent by the string.

bones ; 2d, their natural curves (for rachitic bones bend in the direction of
these curves) ; 3d, contraction of the muscles ; 4th, the weight of the trunk.

Portal ( Observations suf la Mature et le Traitement du Rachitisme, ou
des Courbures de Vdr'Colonne vertebrate, etc. Paris, 1797) describes the changes
which the bones undergo in this disease. He points out the-general diminu¬
tion in their length and diameter in rachitic subjects, after the growth of the
frame .is completed, the tumefaction and increased vascularity of particular
bones during the active stage, due to effusion of watery, sanguinolent, of
lymph-like materials into the cancellous structure. In other cases he found
the cells filled with cartilaginous substance. He sometimes found rachitic
bones indurated and hypertrophied. He also describes the coexistence of
hypertrophy of brain-tissue, sometimes with softening, at other times with
induration of it. The muscles rarely present- their natural colour and con¬
sistency, being whiter than common, sometimes resembling fat; and occa¬
sionally the fibres are contorted; shortened; and horny (adipose and fibrous
transformations), as Glisson and Mayow had already shewn.

Stanley ( Med.-Chir. Trans, vol. vii.) shews that the greatest amount of
secondary induration occurs where the Curve is most considerable.

Duval (Apergusur les principales Differ mites, Paris, 1833) regards the
changes in rachitic bones to be due to inflammation of the periosteum.

Guerin {Mem. sur les Caracteres generaux du Rachitisme , 1839) divides
the alterations of the bones into three stages : 1. sanguinolent infiltration into
and between all the tissues of the bone : 2. gelatinous matter taking the place
of the sanguinolent; 3. subsequent induration of the bone—eburnation.

Rokitansky (Syden. edit. 1850, vol. iii. p. 174) describes two forms of
rachitis, the gelatinous and cartilaginous : he confirms the views the author
has expressed of the dissimilarity of rachitis and tuberculosis, or scrofula, and
of the conjoint affection of the muscles.

Excepting the opinion Of Duval, who regards rachitic affection of bones
to be due to periostitis, the author finds amongst special writers on rachitis
no investigation of the nature of the dynamic process by which the phy¬
sical changes are induced. Taking into consideration the acknowledged
predisposing and exciting causes, the rachitic cachexia presents this analogy
with the strumous and the scorbutic cachexiee, that in consequence of the
action of the predisposing and exciting causes, the blood is altered and im¬
poverished; hence an abnormal process of nutrition is established in those
parts of which at the time the development and growth are most active;
these being in rachitis, the osseous system and its appendages, and the
central organ of nervous system. It is the character of these abnormal pro-

238

INTIMATE NATURE OF RACHITIS.

Flattening and distortion of the ribs, with projection
of sternum, are sometimes produced in young children
independently of general signs of rachitis, and without
local indications of that disease in other parts, through
impeded development of the lungs (during the growing
period of life). Thus the author watched in consultation
with Mr. Mimpress, a child, get. 5, who presented no
general or local sign of rachitis, but who after a chain of
infantile dangers—pertussis, broncho-pneumonia, convul¬
sions, and laryngismus stridulus—became rapidly affected
with prominence of sternum, and flattened cartilages of
ribs and sides of chest. It is unnecessary to describe in
this place the ordinary shrinking and deformity of chest
resulting both in children and adults after recovery from
chronic pleurisy or empyema (see Lecture on Spinal Cur¬
vature).

Amongst older writers many interesting notices of
severe rachitis occur. In the work of Ishmael Abulfeda,
biographer of Mahomet, mention is made of one Gattib,
a noted fortune-teller, who had no hones. “ Hominis
sine ossibus exemplum habemus illustre.” The bones of
this individual were, at all events, so flexible, that he
could be rolled up from the feet to the collar-bones like
a cloak: “ complicari poterat instar vestis.” Houlier, a
noted physician of the Faculty of Paris, relates: “Cuidam
mulieri Lutetise totum corpus molle et sine ossibus fuit.”*
(Portal, Opus cit.) ]

cesses of nutrition not to proceed imperceptibly or in a latent manner, but
to be accompanied with more or less of hypersemia, giving rise to some of
the physical evidences of their existence. It is not a mere passive cessation
of deposit or absorption of suitable materials (in rachitis the earthy sub¬
stances) ; but in rachitis, struma, and scorbutus, in each of which states the
bones are apt to be affected during their developmental period (in scorbutus
during reproduction after fracture also), the process is accompanied with an
active vascular reaction allied to inflammation, itself regarded as another
process of abnormal nutrition.

* Actse See. Nat. Curios.

239

LECTURE XIV.

Pathology of congenital distortions—Congenital distortions represented
by acquired deformities—-Associated muscles conjointly affected ■—
Analogy with strabismus and stammering —- Congenital club-foot ■—
Influence of maternal imagination—How affected—Influence of
malposition in utero.

Congenital Distortions.

The observations on tbe pathology of distortions in ge¬
neral will have prepared you for the study of congenital
deformities. You will remember that the reason formerly
assigned by me for commencing with the study of distor¬
tions arising after birth was, that greater facilities are pre¬
sented for examining their production and mode of develop¬
ment; that in comprehending that which daily occurs
under our observation, we are enabled to apply the infor¬
mation thus acquired to unfolding the apparent intricacy
of that which takes place in the recesses of the uterus.
One of the most striking facts elicited from comparison of
non-congenital with congenital deformities is, that certain
deformities which are slowly acquired in extra-uterine exist¬
ence, in consequence of paralysis, or suddenly through spastic
action of muscles, are faithfully represented in certain de¬
formities which originate during intra-uterine life. This
fact is no sooner seized than the mind of the observer is at
once led to the inference, that the causes which have pro¬
duced these identical phenomena must have been identical.
The pathologist then more closely investigates the subject,
compares anew the apparently identical changes of form
which the parts of the human frame have undergone; what
the identical causes are that have produced identical results;

240

CONGENITAL DISTORTIONS.

and lastly, he compares the causes which he knows operate
after birth in the production of deformity, and determines
whether these causes can be those which operate in utero.

The class of non-congenital deformities which so greatly
resemble the congenital affections are the contractures; and
you will remember that paralysis and spasm, and other
causes enumerated in the lectures on contractures, are the
precursory phenomena of these alterations from the normal
form. In short, the causes of permanent deviations from
the natural form in these cases operate by destruction of
equilibrium in the power of opposing sets of muscles. It
is unnecessary again to occupy more time with the manner
in which paralysis arid spasm produce deformity, it is suffi¬
cient to bear in mind, that when the equilibrium of opposing
sets of muscles is destroyed, those that preponderate ulti¬
mately become organically or structurally shorter,* perma¬
nently adapted to the altered relation of the parts contracted,
whilst the overpowered muscles* being permanently elon¬
gated, are further weakened in their texture; and even when
the original cause of destruction of equilibrium is removed,
the parts do not spontaneously return to a natural form.

The doctrine of identity of cause in the production of
non-congenital and congenital deformities presupposes the
admission that similar diseased or fortuitous conditions may
occur previously as well as after birth. This doctrine can,

* Langenbeck’s experience throws doubts upon the reality of this struc¬
tural shortening; since, during the state of anaesthesia, muscles which have
"been for many years contracted may be entirely elongated. ( Commentatio de
Contractura et Ancylosi Genu nova methodo violentce extensionis ope sanandis.
Berolini, 1850. See pp. 41, 60 of these Lectures.)

Langenbeck states permanently elongated ; but the author, on the con¬
trary, has found that when the state of anaesthesia has passed away, the
shortened muscles again contract, though their subsequent elongation is
facilitated. It appears to the author that the anaesthetic agent removes for
a time volition and the organic contractility of the fibres, in consequence of
which the mere physical structural shortening of the fibres is easily overcome ;
and this physical shortening once overcome, the subsequent contraction is
rendered less resisting.

ETIOLOGY.

241

in the present day, be scarcely disputed; too many instances
of disease (beyond the domain of the pathology of defor¬
mities), present at the moment of birth, or of which the
traces are evident at birth, daily occur, to leave doubt in
the minds of rational pathologists. I need mention only
variola and tuberculous disease. The causes of contractures,
you may recall to mind, are spasm or increased energy of
certain parts of the muscular system, paralysis or diminu¬
tion and deprivation of energy, and accidental causes, which,
by inducing temporary malposition of a limb, occasion a
contraction of some muscles, relaxation of others, and de¬
formity. We will now consider some of the facts on which
rests the presumption that these causes may affect the foetus
in utero as well as the individual at a later period of exist-
ance. It is a fact that children are often born with this de¬
formity (see fig. 98), the most common of congenital dis-

CONGENITAL DISTORTIONS.

tortions, termed Talipes varus, and when presenting the
average degree of severity, the contraction of certain muscles
on the posterior and internal surfaces of the limb resists
the best-contrived mechanical modes of treatment, and,
though partially overcome, continues throughout life. Ex¬
perience demonstrates that this stubborn resistance to me¬
chanical extension is, in non-congenital cases, only offered
by structural shortening combined with augmented energy
of the muscular fibre ; and the practitioner is led to infer
a similar condition of muscles, in congenital Talipes varus.
Again, cases of congenital deformity occur, though hut
rarely, in which a paralytic condition of certain muscles
unquestionably exists.

It is, then, an indisputable fact that certain deformities
present themselves at birth, in which certain sets of muscles,
usually the same class of muscles most obnoxious in after
life to spastic contraction, namely, the flexors and adduc¬
tors, are found actively contracted; and when, in addition,
we observe numerous deformities in the same individual,
as, for example, contracted knees, contracted hips, club¬
hand, in all of which the flexors and adductors, or their
analogues, are the muscles specially contracted, we are led
to assume that a common cause has affected these different
parts of the frame.* We cannot conceive that an accidental

* A review of the opinions of some earlier writers on the causes of con¬
genital distortions may facilitate the study of the subject. Talipes varus,
or congenital club-foot, is the most common of congenital distortions, and
has elicited most attention. The views entertained of this affection may serve
as a type of the opinions formed of distortions in general. ;

Duvemey asserted that the monstrosity depends on the unequal contrac¬
tion of the flexors and extensors, the weakerf muscles being drawn by the
stronger and more contracted in an opposite direction; whilst the unfortunate
patients instinctively favour the increase of the deformity by turning the feet
in the direction of the action of these muscles.

BoyerJ admitted the inequality of power of the abductor and adductor

t TraitS des Maladies des Os, tome ii. chap. 3.

t Lepons du citoyen Boyer, redigees par A. Richerand: Paris, 1803, tome ii. p. 247.

CAUSES OF CLUB-FOOT.

243

or mechanical cause, acting from without upon the foetus,
could act on so many articulations in an invariable manner.
A satisfactory explanation of the concurrent affection of

muscles to be the origin of varus and valgus, but believed that congenital
varus might be produced by an improper position of the foetus in the uterus.
He attributed the occurrence of varus after birth to the nurse having permitted
the infant to place the limbs in irregular positions; and as the bones are at
this period cartilaginous, and can be compressed into any form, he recom¬
mended that the cure of the distortion should be undertaken immediately on
being perceived. He was also of opinion that if the process of ossification be
completed during the continuance of the deformity, the bones will for ever
retain their form, and the distortion of the limb remain irremediable.

Scarpa thought that Duvemey had mistaken the effect for the cause, and
stated that proof might be adduced of the primary origin of the disturbance
in the osseous system, through which the insertion of some of the muscles
became approximated to their origin, and that of others removed from it;
the former becoming shortened, the latter elongated, in the same manner as
distortion occurs in fractures and dislocations. He, however, concedes, that
in infants, after the occurrence of distortions of the bones, the disturbance of
the equilibrium in the power of the muscles greatly contributes to maintain
the deformity. (Opus infra cit.)

Jorg,* on the contrary, distinctly states that the action of the muscles is
the proximate cause, and naively regrets that Scarpa omitted to publish the
proofs of the primary occurrence of distortion of the bones. Jorg was led to
this opinion by witnessing the occurrence of non-congehital varus from an
apoplectic seizure.

Rudolphif gave a more complete view of the origin of T. varus than any
of his predecessors, and one more consistent both with physiology and patho¬
logy. He concluded that congenital Talipes, and the analogous deformity of
the hand (club-hand), arise from disordered influence of nerves on muscles in
the foetal state, by which their contraction is prematurely excited ,% and often
in so vehement a manner, that the mother experiences pain from the convulsive
motions ; the limbs thus become distorted, and permanent deformity is often
thereby occasioned. He observes, that the authors who have maintained the
injurious influence of external and mechanical causes, such as pressure of the
uterus, through an improper position of the foetus, appear to have been un¬
aware that these distortions are not unfrequently witnessed in embryos of
three or four months. § Rudolph! not only points out the influence exercised

* Op. cit. p. 87. t Physiologie, 6tes Buch, p. 323. t lb- P- 319.

§ Embryos of three to five months, affected with talipes, and exhibiting malformations
or deficiency of the cerebrum and medulla Spinalis, are common in anatomical museums.
Some areanencephalous, and others hemicephalous, both the hands and feet being affected
in this manner, shewing the extensive participation of the system in the disturbance and
destruction of the nervous centres.

244

CONGENITAL DISTORTIONS.

certain classes of muscles rather than of others can only he
given by reference to a cause acting within the foetal organ¬
ism. When, by this process of reasoning, the field of re-

on the muscles of the extremities, by powerful and general causes affecting
the entire nervous system of the foetus, but remarks that Talipes often occurs
after birth, in infants in other respects well-formed, from simple spasm.

Delpech,* in his first publication on the subject, adduces but few impor¬
tant arguments in support of the opinion adopted by him, that the deformity
of club-foot arises from malformation of the tarsal bones.f He, however,
appears to have been aware of the insecurity of the basis of this theory, and
admitted that the success attending his curative exertions might be advanced
as an argument against it; having followed that observation by inquiring how
it happened that these affections were so speedily remedied, if they depended
on serious malformations of the bones. He also raised the question whether—
admitting that a simultaneous inclination of all the bones towards the same
side favoured the opinion that the distortion arose from muscular action—
a derangement of the muscles, affecting their length, might not be capable of
producing a disturbance of the position of the bones, and consequent defor¬
mity of the limb. He considered the existence of a conjoint affection of all
the anterior or posterior muscles of the leg, by which their development in
relation to the hones might be impeded, and a shortening result, to be more
natural than that the entire bones should become so affected as to alter their
. form on a regular and systematic plan, and thus produce an universal devia¬
tion of the whole of the articular surfaces in one direction. In opposition to
these arguments, the importance of which he admitted, he asserted that the
change in the form of the bones is observed to precede the shortening of the
muscles, but, like Scarpa, adduces no proof in support of this assertion. He
also states, that at birth the muscles do not contribute to the maintenance
of the deformity, the foot being at that period readily reducible to the proper
position.

This statement is erroneous; for although the foot can frequently be re¬
stored by pressure to its natural position, many instances occur in which a
slight amendment only can be thus effected j and in all cases the resistance
of the muscles is perceptible. Delpech, however, conceded with Scarpa the
influence exercised by the muscles on the progress of the affection, in expla¬
nation of the increase of the deformity, j: As Delpech, in a treatise§ pub¬
lished six years afterwards, renounced the opinion of the dependence of.
Talipes on primary disease of the bones, the relation of his earlier opinions
might, have been unnecessary, had they not been still entertained by other
authors. He was then induced to' conform to the theory, that these distor¬
tions arise from muscular action, by witnessing the occurrence of two cases of

* Chirurgie Clinique de Montpellier: Paris et Montpellier, 1823.

t lb. p. 166. t Op. cit. p. 199. § De 1 Orthomorphie : Paris, 1829.

CAUSES OF CLUB-FOOT.

245

search is narrowed, we inquire which of the systems of the
foetus can, by its derangement, occasion the abnormal con¬
ditions of muscle on which congenital deformities depend.

varus-like deformity, at an age when the bones had acquired complete de¬
velopment : one, that of a soldier whose external popliteal nerve had been
injured by a gun-shot wound in the thigh, succeeded by paralysis of the
peronei, tibialis anticus, extensor longus digitorum, and extensor proprius
pollicis muscles (see p. 128 of these Lectures). Deformity ensued through con¬
traction of their antagonists. The patient, on recovery from the first effects
of the injury, walked on the external edge of the foot, then on the instep, and
ultimately on a protuberance formed by the anterior extremity of the os
calcis, the dorsal surface of the os cuboides, and the malleolus externus* (see
Contracture).

The other case was equally interesting, as it demonstrated the production of
a similar deformity from an opposite cause. A woman at the age of twenty-
four years became affected with abscesses in the thigh and necrosis of the
femur; and during the progress of the disease, which continued for three years,
contraction of the posterior muscles of the leg occurred, as Delpech says,
either through sympathy or propagation of the deep-seated inflammation to
the sciatic nerve, the foot being drawn both downwards and inwards, and dis¬
torted so as to resemble complete varus (see Ankylosis). Delpech states that
he had never previously witnessed so severe a case of varus, the toes being
drawn to within three inches of the heel. Notwithstanding the abandonment
of the opinion of the existence of a primitive affection of the osseous system,
and the subsequent assumption that the deformity was attributable to active
contraction of the muscles from affections of their nerves, followed by struc¬
tural shortening through suspended development and atrophy, he supposed that
the gastrocnemii were the only muscles involved in the production of varus,
the inward inclination of the foot being gradually produced by pressure exer¬
cised in the act of walking. It is doubtful whether Delpech ever witnessed
the more severe gradations of T. varus, in which the child, on the first at¬
tempts to walk, inevitably treads on the instep; although he describes the
presence of a slight inward tendency of the point of the foot at birth, which
he endeavours to explain by stating that the posterior tuberosity of the os
calcis spontaneously inclines somewhat inwardly. But even were this the
case, and the heel likewise drawn further inwardly by the contracted gas-
trocnemii, it would follow, in the absence of contraction of other muscles
which might direct the toes inwardly, that they would be directed outwards.
It will, however, be shewn, that the posterior extremity of the os calcis

* The author has never seen the malleolus externus applied to the ground, notwith
standing the extent of the deformity; hut the part is sometimes invested with a corn
produced by friction against the shoe.

246

CAUSES OF CONGENITAL DISTORTIONS.

Disturbance and disease of the nervous system presents
itself as the key to the solution of the difficulty ; and we
may next inquire whether other facts derived from obser-

inclines externally towards the fibula. (See Morbid Anatomy of Club-foot.)
Moreover, another cause of the inward inclination of the front part of the
foot exists — contraction of the adductors.

Cruveilhier,* notwithstanding his valuable contributions to the pathology
of club-foot, adopted the unsatisfactory explanation of its production by a
mechanical cause. He, however, arrived at the conclusion, that club-foot is
not produced by pressure exercised by the uterus on the foetus, or by any ex¬
ternal pressure acting on the mother ; being aware of the birth of infants
affected with Talipes during whose uterine existence there had been no defi¬
ciency of liquor amnii, and of that of well-formed infants wherein a paucity
of liquor amnii had been observed. . He was also cognisant of the fact, that
pregnant women who have received blows and contusions on the abdomen,
and others in whom, from the desire of concealing pregnancy, injurious pres¬
sure on the uterus had been maintained, have nevertheless given birth to
children free from distortion; whilst many women, who had neither been ex¬
posed to injury nor subjected to pressure on the uterus, have been delivered
of infants affected with Talipes. But, prepossessed in favour of the existence
of a mechanical cause of the deformity, he became convinced that club-foot
and club-hand arise from the limbs of the foetus being arranged in improper
positions in relation to each other and-to the trunk of the body, by which
their mutual development is impeded. In corroboration of this opinion, he
affirms that the carpus being composed of small bones, and its articulation
very loose (the reverse of the ginglymoid articulation of the ankle), no de¬
formity of the hand analogous to Talipes varus could occur, as the foetal dis¬
tortion of the carpus and metacarpus disappears after birth, the removal of
the pressure causing their return to the natural form and position. The in¬
accuracy of the statement of the spontaneous disappearance of club-hand
after birth proves the fallacy of the inference. The author observed, in
several foetuses contained in the Berlin Museum affected both with club-hand
and club-foot, that the hands could be reduced by pressure to their proper
position; but, like club-foot, on the removal of the pressure, they relapsed
into the distorted state. The author has likewise seen a youth, aged seven¬
teen, born with these deformities of the feet and hands : the distortion of the
former gradually increased through the injurious effects of exercise, the rigidity
of the contraction being so great, that pressure with the hands effected no
diminution of the deformity. The hands, the left being the more distorted,
had remained in a position similar to that presented at birth, except that,
until he commenced exercising volition, they were maintained in an extreme

* Anatomie pathologique C u Corps humain: Paris, 1830, livraison ii.

DISEASE OF FOETAL ORGANISM.

247

vation offostal phenomena justify the opinion that derange¬
ment of the nervous centres occasions the distortions in
question. It is remarked that foetuses which have evidently

state of flexion and pronation, being closely applied to the anterior and inter¬
nal surface of the fore-arm. At this period the youth endeavoured, by exert¬
ing the extensor and supinator muscles of the wrist, to overcome the con¬
traction of the flexors and pronators. Hence the hands were not at all times
so fully contracted as at birth; but on the withdrawal of the influence of vo¬
lition from the extensors and supinators, these muscles yielded to the contracted
flexors and pronators, and the hands assumed the original distorted position.
The left was then closely applied to the anterior and internal surface of the
fore-arm ; the right, being more controllable by the extensors and supinators,
spontaneously occupied a less distorted position. The resistance of the flexors
and pronators was distinctly perceived on attempting to place the hands in a
proper position. Had Cruveilhier witnessed a ease of club-hand in the living
subject, he would not have asserted that this affection is spontaneously reme¬
died after birth. Club-hand suggests many important reflections, being pre¬
cisely analogous to Talipes varus. The simultaneous existence of flexion and
pronation in club-hand is strictly comparable with the extension* and adduc¬
tion of club-foot.f

When both extremities are affected with Talipes, the left frequently ex¬
hibits the higher grade of deformity : this was the case in the present instance.
The distortion of the hands thus presented a further analogy, as the muscles
of the left were less controllable by volition, occasioning a greater deformity.
The superiority of the right hand might be explained by the supposition that
it was more employed than the left; but this patient was unable even to use
the right in the majority of actions in which it is usually employed; and to
supply the deficiency, he generally resorted to the use of both, more particu¬
larly in the act of grasping or lifting. This explanation is inapplicable to the
left foot; for it cannot be contended that persons affected with Talipes in
each foot exercise either in preference. The existence of this analogy between
Talipes and club-hand strengthens the opinion of the dependence of these
distortions on abnormal muscular contractions. It might, indeed, be con-

* See note, p. 110.

t Many years since the author witnessed an adult congenital case of club-hands and'
club-feet. The distortion of the hands corresponded with the above description, and the
analogy with club-foot]was still greater; as, iu addition to the affection of the flexors and
pronators of the wrist, several muscles in the palm of the hand, particularly the opponens
and flexor brevis pollieis, were contracted in precisely the same manner as the muscles
of the great toe in Talipes. The left foot was similar to fig. 105 of these Lectures; the right
resembled fig. 107. Distortion of the hand may also occur from unnatural contraction of
the extensors and supinators of the wrist (see p. 148 of these Lectures). The existence
of this distortion was predicted by the author from analogy in Treatise on Club-foot, §c.,
1839, Introduction, p. xxxix.

CAUSES OF CONGENITAL DISTORTIONS.

suffered derangement in the development of the nervous
centres, such as those denominated hemicephalous or ace¬
phalous, or affected with spina bifida, very frequently pre-

sidered a singular occurrence that a mechanical cause,—such as the limbs
during foetal existence becoming twisted into unnatural positions, and imped¬
ing their mutual development,—should invariably induce relaxation, followed
by shortening of certain muscles physiologically associated, and also stretching,
followed by elongation of other muscles.

But in the demonstration of the dynamic cause of club-foot, allusion to
the analogy of club hand is unnecessary: the characters of the former maybe
further investigated without any reference to club-hand. As in Talipes varus,
the navicular, cuboid, and cuneiform hones, with the metatarsus and toes, are
inwardly inclined by the agency of external pressure, so that the navicular
hone is brought into contact with the internal malleolus, how happens it that
these parts are never thrust in the opposite direction by the navicular and
cuboid bones becoming forced from their connexions with the astragalus and
calcaneum, and by the cuboid bone becoming placed in contact with the ex¬
ternal malleolus ? If the distortion were produced by external violence, the
mechanical arrangement of the tarsal bones would permit the os naviculare
and os cuboides to be forced outwardly as readily as inwardly. But this
never occurs, as no muscles capable of drawing these bones outwardly are
inserted into them. Talipes valgus is the deformity most opposed to Ta¬
lipes varus ; hut although an affection as opposite as can he produced by
the contraction of the contrary^ sets of muscles, yet if the distinctive cha¬
racter of T. varus is described as an inward twisting and rotation of the
front of the foot, by separation of the navicular and cuboid bones from
the astragalus and calcaneum, the peculiarities of Talipes valgus could not
be contrasted as opposite; for in this distortion the entire foot is main¬
tained in a certain position from muscular action, but no outward twisting
in particular of the front of the foot takes place from separation of any of
the tarsal bones. The constant recurrence of the same series of pathogno¬
monic symptoms in Talipes contributes to prove its non-dependence upon
external causes. Every disease is characterised by a peculiar mode of evolu¬
tion, accompanied by the same essential symptoms. Talipes has its distinctive
traits equally with peripneumonia, variola, epilepsy, or hernia; indicating that
its production takes place according to certain internal pathological laws, and
not from the operation of external agents.

Tourtual (Opus infra cit.) inclines to an opinion of Cruveilhier, that the
frequent co-existence of Talipes in both limbs, and the occasional accompa¬
niment of “ monstrosities of other organs,” are proofs of its dependence
upon an unnatural shape of the astragalus. But this complication in foetuses
affected with Talipes tends less to prove its dependence on primary malfor-

DISORDER OF FCETAL NERVOUS SYSTEM.

sent club-foot, club-band, or other deformity. The co¬
existence with congenital club-foot of congenital squinting,
and even congenital stammering or misenunciation,—dis-

mation of the bones than upon some powerful cause disturbing the nervous
centres, and affecting the functions ; and in severer Talipes impairing the de¬
velopment of the nerves and muscles of the distorted limb.

Philip von Walther* has attempted an ingenious but insufficient explana¬
tion of Talipes. The untenableness of his theory may be demonstrated by a
reference to the discoveries of others in the history of the development of the
human embryo. Were its accuracy admitted, we should return to the notion
that Talipes is a monstrosity by defect. He states: “Talipes is a natural
grade of the development of the foot, and embryos of three or four months
very frequently retain one or both feet in this state. The foot as well as the
hand (and other members of the trunk) are formed from a bladder filled with
fluid, which bursts along its internal side, the inner and outer edge of the
foot resulting from the margins of the rupture, the sole being formed by the
space afforded by their expansion and separation. The future external margin
of the foot is at first drawn downwards ; the sole, which is still very concave,
presents internally ; the future internal margin is directed upwards ; and the
back of the instep looks outwardly;” thus constituting a complete Talipes
varus. From this it would follow, that every foetus, at an early period of
development, has two club-feet. But if Talipes varus be a state of natural
embryo-development, the inquiry may be instituted as to which of its natural
stages Talipes equinus and Talipes valgus are respectively referrible. By
whatever further stretch of imagination this theory may be applied to the ex¬
planation of Talipes equinus, its application to Talipes valgus is decidedly
inadmissible.

His explanation of the manner in which the feet (Talipedes vari) of all
embryos, during the progress of development, are converted into natural,
well-formed feet, is equally ingenious. He states : “The flexors of the foot
(tibiales anticus and posticus, the gastrocnemii,f and more particularly the
soleus and plantaris), and the flexors of the toes, are the muscles first formed,
and the action of which originally predominates. The extensors (peronei and
extensors of the toes) are subsequently formed, and oppose the first series of
muscles, and ultimately keep them extended ; the foot is gradually directed
outwardly, the sole becoming flattened; but the external margin of the foot

. * System der Chirurgie, Band i. p. 349 : Berlin, 1833.

t P. von Walther regards the muscles on the posterior aspect of the leg as flexors, in
consequence of their pathological relations. See note, p. 110. He has erred in classing
the tibialis anticus with the gastrocnemii as a flexor; for although it bends the foot, it
is, according to his nomenclature, an extensor. Observing its contraction in T. varus,
he could not separate it from the gastrocnemii: he should therefore have denominated
it adductor in relation to this distortion, from its assisting to draw the foot inwardly.

250

CAUSES OF CONGENITAL DISTORTIONS.

eases which clearly depend either on the increase of the
involuntary or decrease of the voluntary powers of certain
orbital and laryngeal muscles, corroborates these views.

is not drawn outwardly (and upwards), in consequence of the extensors (and
abductors) not having at this period acquired sufficient power. Should the
foot remain in this grade of development, varus will be discovered at birth,
the contracted and shortened flexors preponderating over the elongated and
debilitated extensors, as they naturally do at an earlier period of uterine
existence. ... The propensity of the generality of infants to tread on the
outer edge of the foot results from the circumstances attending the former
stage of development—the last remains of a slight grade of T. varus.”*

A more cogent argument against the theory of P. von Walther is the cir¬
cumstance, that other observers of the phases in development of the embryo
have not witnessed the formation of the hands and feet from a bladder, by the
rupture of which, and the separation of its margins, the edges of the foot are
formed in the manner described by this anatomist.f

StromeyerJ attributes varus to increased energy in the affected muscle,
morbid contraction or motion in the muscular fibres—tonic spasm. The
muscle, through constant contraction, becomes inert with reference to its par¬
ticular function, but continues in a state of tension from its fibrous structure.

The inward inclination of the fore-part of the foot, which constitutes the
difference between T. varus and T. equinus, has by Stromeyer been attributed
to deficiency of the internal malleolus; Delpech and Cruveilhier are also of
opinion that this cause greatly contributes to the maintenance of T. varus.
The author has never observed, in foetal or adult instances of dissected T.
varus any material deficiency of this process. After long continuance of the
tarsal bones in their improper position, and consequent compression or fric¬
tion by the navicular bone, it occasionally becomes smooth at the extremity;
but this cannot much affect the ankle-joint. The deficiency, when existing,
should be regarded as an effect, and not as a cause (see figs. 43, 110, and 111).

* Dr. Pockels directed the author's attention, during a visit to Brunswick, to the
opinion that T. varus is an unnatural increase of the propensity of children to turn the
feet inwardly. This propensity depends upon the organisation of the muscles and the
structure of the ankle-joint, which tend, in the absence of volition, to produce an inward
inclination of the toes. During fcetal existence, and prior to the exercise of volition in
infants, as well as during sleep, the limbs are under the influence of the involuntary con¬
tractile powers of the muscles. The gastrocnemii and adductor muscles, constituting the
larger mass of muscular fibres, maintain in the embryo and infant the inward inclination
of the toes and the elevation of the heel, although the foot is occasionally moved in every
direction. To explain more fully—the child is at first disposed to tread on the external
margin of the foot, because the muscles are only gradually subjected to the control of
volitions but by continually striving against the involuntary contractility of the muscles,
perfect use of the feet is finally acquired.

t See Valentin, Entwickelungs-Geschiehte des Menschen, p. 245.

% Ueber Paralyse der Inspirations-Muskeln: Hannover, 1836.

CO-EXISTENCE OF SEVERAL DISTORTIONS.

251

In the case of strabismus and psellismus no question can
be raised of the possible operation of causes independent
of the foetus, accidental pressure for example. If further

Maisonnabe believed that T. varus depends on shortness of the plantar
fascia. The opinion of the dependence of congenital distortions on shortening
of fasciae may, as Delpech observes, he refuted by the single observation, that
it is insufficient to explain the occurrence of Talipes valgus.

The ligaments cannot directly influence the production of the deformity ;
but the restoration of the foot is impeded by their diminished length, the
result of long continuance in an improper position.*

Stromeyer has stated, that if contraction of the gastrocnemii muscles occur
during the later period of uterine existence—after the ankle-joint has acquired
a certain degree of firmness by the development of the internal malleolus, and
the ligaments of the joint having been fully formed—Talipes equinus, either
with or without a slight inward inclination of the foot, is presented at birth ;
whereas should the muscular contraction occur at an earlier period, Talipes
varus is the result.f And as the majority of cases of Talipes equinus, and the
milder forms of Talipes varus, are curable by division of the tendo Achillis
only, he considered the shortening of the muscles of the calf the essential
cause of the whole of these distortions, the peculiarities of each being re¬
garded as secondary phenomena. He likewise doubted the influence of the
anterior tibial muscle in the production of Talipes varus, and observed that
this muscle cannot draw the front part of the foot inwardly whilst the heel is
elevated and the foot extended beyond a right angle with the leg and conse¬
quently that as this extension takes place in Talipes varus, the influence of
the tibialis anticus must of necessity be very slight, and of secondary import¬
ance. He admitted the existence of contraction of the tibialis posticus, but
considered that the situation of this muscle cannot permit any great contrac¬
tion of its fibres, and entertained doubts of the utility of dividing its tendon.

Guerin (Opus infra cit.) ably advocates the dependence of varus upon
derangement of nervous system of the foetus. Duval (Op. inf. cit.) acknow¬
ledges both uterine pressure and cerebro-spinal uterine influence. An objec-

* Cruveilhier erroneously contradicts the opinion of Scarpa, that in T. varus the
external ligaments of the ankle are elongated. The author has found the internal lateral
or deltoid ligament shortened, and possessing considerable density. Mackeever {Edin¬
burgh Medical Journal, vol. xvi. p. 220, 1820) states that in the T. varus of an infant in
whom the os seaphoides with the os cuneiforme internum were drawn close to the inter¬
nal malleolus, he could not abduct the foot until he had divided this ligament.

t Stromeyer, Beitrage zur operativen Orthopadik, Oder Erfahrungen iiber die suhcu-
tane Durchschneidung verkiirzter Muskeln und deren Sehnen: Hannover, 1838.

1 The author, in his inaugural dissertation, Berlin, 1837, has expressed the same
opinion; but at the period of the publication of his Treatise on Club-foot, fyc., 1839, was
compelled to differ from his respected and experienced friend, to whom he is indebted for
the great and lasting benefit of the removal of much lameness. (Equino-varus aequisitus.)

252

CAUSES OP CONGENITAL DISTORTIONS.

testimony be requisite to convince you that these defor¬
mities depend primarily on derangement of the nervous
system, analogous, if not identical, in its nature with the
derangement of the nervous system which occasions similar
deformities during infancy, childhood, and adult life, you
may inquire into the possibility or probability of the ner¬
vous system of the foetus being subjected to disease, and
expect me to describe the manner of its production. The
most frequent sources of derangement of nervous system of
the infant and child are disorders of nutrition, debility of
nervous system inherited from the parents, and undue ex¬
citation of the delicate organisation of these parts. Similar
sources of derangement appear to me to exist during uterine
existence. I have questioned many parents who have given
birth to infants thus affected, who could assign no other
cause for the affliction than that of having suffered from
general derangement of health during pregnancy. Several
mothers have in this respect strongly contrasted the parti¬
cular gestation with former pregnancies. Others have re¬
marked the unusual extent of the intra-uterine movements
of the foetus, an almost convulsive condition. From ana¬
logy it may be inferred that no more probable cause of
production of derangement of nervous system of the foetus
could occur than general derangement of the health of the
mother, whether this derangement operate through the
nervous system of the parent or by impaired nutrition.

Instead of club-foot, for example, being considered
what it really is, a mere distortion of parts originally well
formed, the popular notion is, that it depends, on a defla¬

tion which, may be offered to Guerin and Duval’s valuable writings is, that, fol¬
io wing the habit of many of their countrymen, they entirely overlook the labours
of their predecessors in other countries. Thus they take credit for originality
in the same opinions on the etiology of varus, which the author put forth in
his dissertation four years before the publication of Guerin and Duval’s works
—opinions derived from the study of the same materials possessed by himself
as well as by them—Nature and the writings of those who preceded him.

FROM MATERNAL IMPRESSIONS ?

253

ency of some of the parts of the limb ; that it is a malfor¬
mation, a monstrosity, a lusus naturae, or an arret de deve-
loppement. This, like other almost equally obsolete opinions
of the medical profession, has obtained a firm hold of the
minds of the public, and will retain it for generations after
the advance of science has introduced other explanations
of the nature of the disease. Believing also that it is solely
a misfortune afflicting the infant anterior to birth, its pro¬
duction has been attributed, like that of other so-called
malformations, to some occult maternal influence acting
upon the embryo—to the strange ideas and freaks of ima¬
gination which occasionally affect pregnant women.

Many women who have borne children afflicted with
Talipes suppose that the cause of the deformity has been
an ordinary fright received during pregnancy; others assert
their conviction that a more alarming fright, consequent
on having seen a person affected with a similar deformity,
has produced the misfortune of their infant. I have, how¬
ever, been informed by many mothers who have brought
children affected with club-foot to me, that they neither
recollected having had any particular fright, nor having
been shocked by seeing distortion in any person during
their pregnancy. Indeed, several mothers have mentioned
that until they beheld the deformity of their infants they
had never seen a club-foot, or had any idea of the existence
of such deformity. I have met with exceptions in the
cases of accomplished and talented females, who distinctly
recollected having seen with pity during pregnancy suffer¬
ing mendicants similarly deformed. A case recently oc¬
curred in which a lady gave birth to an infant affected with
Talipes valgus, which she referred to her having received
a severe shock in traversing, whilst pregnant, the wards of
a public hospital, on the occasion of the anniversary of the
institution. Her attention was particularly directed to the
case of a child recently operated on for a congenital de¬
formity, and, as she assured me, she experienced a peculiar

254

CAUSES OF CONGENITAL DISTORTIONS.

thrill from the contemplation of the child’s condition. This
was a case in which the reality of the mental impression
could be easily substantiated; hut it is unfortunate for the
believers in the influence of such impressions in producing
a corresponding deformity, that on further inquiry I ascer¬
tained that the case of deformity which the lady had wit¬
nessed was Talipes varus, and not Talipes valgus.

It is natural that a sensitive or sympathising female
should not witness misfortune without shuddering, more
particularly when pregnant, and therefore as club-footed
persons are numerous in our streets, it is not surprising
that a woman, on giving birth to a child afflicted with so
great a calamity, should recollect having received a fright
from this cause. Hence a number of such instances, how¬
ever commonly received may be the opinion, tend little to
confirm the idea that infants become thus affected because
the parent had been shocked at the sight of this deformity.
The opinion that a severe fright from any ordinary cause is
capable of inducing club-foot in the foetus is more recon¬
cilable with the theory of the formation of this deformity.

We are ignorant of the existence of any direct con¬
nexion between the nervous and sanguineous systems of
the parent and those of the foetus; nevertheless, as violent
mental impressions exercise so powerful an influence upon
the circulation of the parent, it is not improbable that
derangement of that of the foetus may be thereby produced
sufficient to injure the imperfectly developed and delicate
brain and spinal cord of the infant, and thus induce im¬
perfect development of other organs, and spasmodic con¬
tractions of various muscles, and consequent deformities.

External injury to the limbs during foetal existence—
such as pressure by the parietes of the womb, or the limbs
becoming entangled, and compressing each other—is the
next cause more generally admitted as the source of these
deformities. I shall briefly dismiss the consideration of
this alleged cause. It will suffice to inquire—even if the

FROM MECHANICAL INFLUENCES?

255

relatively large quantity of liquor amnii in which the foetus
is submerged did not, at the early period of uterine exist¬
ence at which these deformities are to be found, oppose an
effectual obstacle to the exercise of pressure upon any por¬
tion of the foetus apart from the remainder,—-how is it
possible that pressure of the walls of the uterus, a mechani¬
cal cause acting from without, should affect the foetal limbs,
by disturbing the arrangement and development of certain
muscles and bones according to certain invariable rules,
instead of acting in an uncertain manner, as external me¬
chanical agents act when brought in collision with the
living body ? It is more in accordance with pathology to
search for some cause resident within the organisation of
the foetus.

This cause is, for the most part, if not wholly, dis¬
turbance of the nervous system of the foetus, in whatever
manner this disturbance may be induced.*

At the commencement of this lecture I remarked the
identity of causes of contractures and congenital distor¬
tions ; and, as I have stated, that the former occasionally
arise from accidental circumstances, such as repose of a
limb in a certain position, it is proper here to inquire
whether this cause may not sometimes operate in utero.
The possibility of this cannot be denied; but observation
of all the facts with which I am acquainted bearing on this
question, leads me to the conclusion that such is not the
cause of club-foot, club-hand, and congenital distortions
in general. (See Malformations.)

[An attentive consideration of the morbid anatomy of
club-foot (see next Lecture) will convince the reader that
a mechanical cause acting from without, such as malposi¬
tion in utero, is incapable of inducing a determinate dis¬
arrangement of the tarsal bones, such as obtains in varus.

* The reader is referred to the lecture on spastic rigidity of new-born
infants for information respecting those distortions, the origin of which, either
a short time before or after birth, may appear doubtful.

256

CAUSES OF CONGENITAL DISTORTIONS.

No other cause than augmented tension of the muscles
inserted into the anterior portion of the tarsus can be ac¬
knowledged to he capable of producing the peculiar dis¬
placement of the navicular bone characteristic of this dis¬
tortion. (See figures 110 and 111.)

Malposition in utero may in some cases, towards the
close of gestation, operate in producing an imperfect posi¬
tion of the feet at birth, a slight distortion, similar to
Talipes equino-varus (p. 100), but not complete varus.
The position in question is not unfrequently witnessed
in large new-born infants; but the characteristic dis¬
placement of navicular bones is absent, and the feet spon¬
taneously, or with the aid of manipulations, assume within
a few weeks after birth a perfectly natural position.

But it is possible that other causes besides dynamic
disturbance of the muscles—other causes than those which
operate directly through the medium of the central organs
of the nervous system, may produce the deformity of
varus. For example, a ligature upon a limb, such as may
he produced by entanglement of the limbs by the umbi¬
lical cord, may so disarrange the normal development of
the limb — may perhaps sufficiently compress the poste¬
rior muscles of the leg, as to excite unwonted structural
shortening of the compressed muscles, and consequent de¬
formity of the foot in a direction which will he deter¬
mined by the particular muscles of which the development
is interfered with by the string-like compression. (See
Lecture on Malformations.) Guerin ( Memoire sur I’Etio-
logie generate des Pieds-bots congenitaux: Paris, 1841,)
describes a case of flattening of the feet, but not true
varus, produced by uterine pressure.

Even the admission that entanglement of the limbs
may possibly produce interference with development, and
cause deformity, although this may not be typical Talipes,
and the inquiry into the proximate cause of the abnormal
movements which precede the entanglement, leads the pa-

FROM MECHANICAL INFLUENCES ?

257

thologist back to the nervous system as the organ prima¬
rily lesed.

During uterine existence the ordinary movements are
automatic, unconscious, or reflex. These do not lead to
entanglement of members by T umbilical cord or with each
other; for whilst these movements are, during gestation,
the rule, Talipes is the exception. When the intra-uterine
movements become extraordinary , as is acknowledged to
be occasionally the case previously to the birth of infants
affected with Talipes, if the excessive movements and
Talipes be admitted to stand in another relation than that
of coincidence, it may be asserted, according to sound
physiological pathology, that the excessive movements are
the result of derangement of the nervous system. Accord¬
ing to this view of the matter, the act of entanglement,
although an apparent link in the chain of causation, may
be left out of consideration, and derangement of nervous
system and the deformity stand in immediate relation as
cause and effect.

The only objection to the dynamic origin of Talipes,
as opposed to the mechanical, to which it is necessary to
allude, is one derived from the observation of the results
of the treatment of the deformity. It has been asserted
that, after relief of the deformity, any indication of per¬
turbed muscular or contractile action is never observed,
and that the muscles previously contracted become per¬
fectly developed. These observations are entirely opposed
to the results of experience. Every surgeon who has
treated even a few cases of congenital club-foot is cogni¬
sant of the tendency to relapse, or that, after complete flexi¬
bility of the ankle has been obtained, the neglect of certain
manipulations and exercises is often followed by return
of considerable contraction. Now it is obvious that if the
dynamic property of the muscles of a joint be intact, and
entire flexibility be obtained, either with or without opera¬
tion, no tendency to relapse should exist; for if the muscles

258

CAUSES OP CONGENITAL DISTORTIONS.

originally contracted be right in their functional activity,
ordinary exercise would, as in the case of a sound limb,
maintain the flexibility. But although volition exists in the
former structurally shortened muscles of a recovered club¬
foot, a tendency to re-contraction—tonic contraction—does
in many cases (especially those most affected) exist; and
in the majority of recovered club-feet, whether treated by
instruments or tenotomy, perfect development of muscles
does not ensue. As volition exists in the contracted
muscles of congenital club-foot, as well as in certain non-
congenital cases (spastic or tonic contractures) both before
and after operation, a further analogy between congenital
and non-congenital deformities exists. Both kinds are
primarily caused by tonic contraction of certain muscles,
followed, in proportion to the duration of the deformity
and activity of the period of development and growth, by
structural shortening. In many cases, especially the con¬
genital, and in many non-congenital cases, the tonic or
dynamic cause of distortion has subsided—the deformity
being only maintained by structural shortening. When
this is obviated by treatment, the cure is complete as
far as the muscles are concerned, and the deformity is on
this account little inclined to relapse. But if in congenital
or non-congenital cases the dynamic cause is still in ope¬
ration, difficulty in maintaining the cure is experienced.]

259

LECTURE XV.

[Varieties of club-foot—Congenital Talipes equinus\—Congenital Talipes
varus — Characters and morbid anatomy—Opinions of older and
modern authors—Importance of studying the anatomy in infants
with reference to etiology, and of adults with reference to cure —
Treatment in the infant—Treatment of adult T. varus.

Congenital Talipes equinus.

[Several varieties of congenital club-foot exist. The
most simple, but at the same time the least frequent affec¬
tion, is Talipes equinus, arising from congenital shortening
of gastrocnemii muscles^ The individual walks solely upon
the point of the foot, upon the toes, or upon the ball of

Congenital Talipes equinus. The deformity of this foot appeared greater in the act of
■walking than it is here represented, owing to the toes then turning inwardly.

CONGENITAL DISTORTIONS.

the foot, without the heel or any of the posterior part
of the sole touching the earth. The heel may he more
or less elevated from the ground, from half an inch to'
five or six inches, according to the age or degree of
severity of the disease. There may also he a difference in
the manner in which the individual treads, as the weight
of the body may he borne either upon the front part of
all the metatarsal bones, which constitutes a pure case of
Talipes equinus ; or the person may be inclined to tread
more upon the little toe, or upon the great toe, when the
deformity approaches the other forms of foot-deformity.

The tendency evinced in T. equinus congenitus to
turn either inwardly or outwardly towards T. equino-varus
or T. equino-valgus, is not dependent upon primary affec¬
tion of either the adductor or abductor muscles of the
foot, but upon the form of the astragalus.

In proportion to the degree of elevation of the heel,
and the intensity of the contraction of gastrocnemii by
which it is held in the abnormal position, the articular
facets of the astragalus are projected forwards from be¬
neath the tibio-tarsal joint, the narrow part only of the
astragalar articulating surface being situated between the
malleoli; hence, during a state of repose, and before the
infant walks, a slight inversion of toes is added to the
original deformity, or, when the individual walks, the toes
incline inwardly or outwardly as described.*

The knowledge that the healthy foot possesses four
normal movements, with corresponding sets of muscles for
their production, and that after birth at least as many foot-

* So uncommon is a pure congenital T. equinus, that its existence has
been denied. The case from which the drawing is taken was the eldest
son of a surgeon, who assured me that the foot had not perceptibly varied
in form since birth. The case, and its treatment with the aid of tenotomy,
was published in detail by the father in the Lancet, 1838. The mother
of this patient subsequently bore nine robust, well-formed children. The
eleventh and last of the family was bom with similar distortion, and recovered
by mechanical treatment without surgical operation.

CLUB-FOOT.

261

contractions occur as there are natural movements and cor¬
responding sets of muscles, with the belief that morbid
muscular action in the foetus is the cause of congenital
distortions, would a priori suggest that the congenital de¬
formities of the foot would be as numerous as the non-
congenital ones. Observation proves this surmise. (The
reader is referred to the diagram of non-congenital defor¬
mities, p. 172 of these Lectures.)]

Congenital Talipes varus.

The number of
instances of conge¬
nital varus proba¬
bly equals that of
all the other con¬
genital distortions
added together.

The frequency
of this particular
distortion corrobo¬
rates the opinion
of its origin from
a lesion of the ner¬
vous system, as it
corresponds with
the greater fre¬
quency of non-
congenital spastic
and paralytic de¬
formity of the an¬
kle than other non-
congenital distor¬
tions. I have, in a
former lecture, at-

Fig. 100.

Slightest degree of congenital club-foot. It may be classed
with varus, because it presents in a slight degree the three¬
fold change of position characteristic of that deformity.
The figure represents the foot hanging down, unsup¬
ported beneath the toes, from which circumstance the
elevation of heel is made to appear disproportionately

tributed the proved

greater frequency of deranged action of the muscles of

CONGENITAL DISTORTIONS.

the foot and ankle to the greater tendency to disease of
the parts of the nervous centres from which the nerves
distributed to the parts most distant from these centres
arise.

T. varus may exist in various grades of severity; it may
be so slight, as at fig. 100, that it appears to he merely an
unnatural increase of the propensity of children to turn
the feet inwardly. It may affect one or both feet. In the
majority of cases the deformity presents the appearance of
this model (fig. 101). It consists of a threefold alteration.

Fig. 101.

Congenital Talipes varus in a youth aged 16. This drawing shews that those points of
the bones of the tarsus which appear in the dissected foot unnaturaUy prominent, may
also be occasionally seen projecting through the skin on the instep.

of position of the foot in relation to the leg,— elevation
of heel, adduction or inversion of the toes, and a rotation
of the foot, analogous to supination in the upper ex-

EXTERNAL CHARACTERS OF CONGENITAL VARUS. 263

tremity. The patient treads on the outer margin of the
foot, principally on the external edge of the metatarsal

Fig. 102

The same foot as the preceding, viewed from behind. It exhibits the state of extension of
the foot; the approximation of the heel, h, towards the hall of the great toe, b; and
the unnatural concavity of the sole, the latter being produced by the contraction of
the tibialis posticus, flexor longus pollfiis, and the muscles of the sole. The letter a
in this and in fig. 101 indicates that portion of the outer edge on which the individual
trod on first placing the foot to the ground; but when in the act of walking he at¬
tempted to throw the weight of the body upon the limb, the toes were thrust more
inwardly, and the tarsal bones outwardly; "by which means the various eminences
seen (fig. 101) on the outer surface of the tarsus were brought into contact with the
iron worn upon the outside of the limb. In consequence of their exposure to consi¬
derable friction, they were covered with indurations of the cuticle. Both feet were
affected in a similar manner, but the left foot to a greater extent.

bone of the little toe; and if the deformity he unrelieved,
it increases as the child grows.

This increase is in part attributable to the improper
manner in which the weight of the body is borne by the
extremity. The perpendicular axis of the limb, instead

CONGENITAL DISTORTIONS.

of passing through the arch of the foot and the sole, falls
to the outside of the little toe ; so that in the act of pro¬
gression the toes gradually incline more inwardly, whilst
the dorsum of the foot tends towards the ground,—see
fig. 103. (Compare with this tendency of congenital dis¬
tortions the progress of non-congenital foot-deformity,
p. 142.) The preponderating action of the adductor mus-

Congenital Talipes varus of the
right foot in a child aged two
years and eight months. The
drawing represents the foot in
the position to which, prior to
the commencement of the cure,
it could he reduced hy pressing
the toes and front part out¬
wards. The outline of the front
part of the foot a shews the
extent of the deformity when
relinquished to the free action
of the muscles, or when the
child attempted to walk. The
letter b indicates part of the
external malleolus, presenting
more posteriorly than in the
sound foot; e, a callosity pro¬
tecting the os cuhoides and its
articulation with the os calcis
from the effects of pressure;
d, the heel elevated to the ut¬
most extent behind the tibia
and fibula; o, external angle
of the trochlea of the astra-.
galus, visible through the in¬
teguments in consequence of
the elevation of the heel.

cles also augments this deformity. Ultimately the dorsum
only is applied to the ground. Occasionally the deform¬
ity presents a higher grade,* even at the moment of birth,
the toes being not merely inverted to a greater degree,
but so much elevated by the action of the anterior tihial
and extensor proprius pollicis muscles, that the inner
margin of the foot is nearly applied to the tibia, as in
these models (fig. 104). Whether the deformity reach

* Dieffenbach makes five grades of varus; it is sufficient in practice to
distinguish three only, as represented figs. 100, 101, and 104.

VARIETIES OF CONGENITAL VARUS.

265

the severest grade
at birth, or subse¬
quently attain it
through the opera¬
tion of the causes
I have mentioned,
it may, during ado¬
lescence and adult
age, present the
most frightful de¬
formity, as repre¬
sented figs. 105
and 106. Loco¬
motion is, in these
cases, wholly effec¬
ted on the dorsum,
or, more accurate¬
ly, on the anterior
extremity of the
os calcis, and the
proper superior surface of the os cuhoides. The mode of
progression is very unsightly, one foot being lifted over the
other, to prevent the toes of one foot striking against those
of the opposite member.* The parts of the foot applied to
the ground suffer much from the friction and pressure to
which they are subjected in walking; a globular callosity
forms over the os cuhoides and adjacent bones, which often
equals in size a small orange.f When it attains this mag¬
nitude the patient, if young, and therefore less experienced
in locomotion, unless assisted by appropriate shoes, expe-

Fig. 104.

Most severe grade of infantile congenital T. varus.

* Club-foot is popularly designated by other names, e. g. bumble-foot in
Somersetshire, reeled-feet in Ireland, &c. (For the various modes of walking
see De Taliped. Varis et Valgis, L. D. Goepel: Lipsise, 1809.)

+ This “ callosity” is sometimes an adipose cushion, sometimes a bursa
(see SymboltB ad Talip cognos. W. J. L., 1887), which promptly disappears
after a few weeks disuse of the limb.

Front view of an adult congenital T. varus. Shewing the deformity of the tarsus and the
swelling (b) which result from the attrition to which the hack of the instep is sub¬
jected; h, the heel. A similar deformity of both feet existed in the subject from
which the drawing is taken.

rienees difficulty in standing still, although he may be en¬
abled to walk and run quickly. Sometimes, except when
seated, bis condition becomes one of perpetual motion; the
comparatively small extent of surface on which the body
rests occasions difficulty in maintaining its balance in the
erect posture, and the sufferer continually moves to avoid
falling. It often happens that the highest grade of de¬
formity occasions less difficulty and pain in locomotion than
the slighter grade ; in this the weight of the body may be

wholly thrown on the little toe..* The extent of surface

* These drawings are added for the purpose of shewing the features of
extreme varus when unchecked by art. They may hereafter only possess an
historical interest, for such instances are even now less common than a few
years since; the greater number of adult cases bearing some traces of the
interference of art.

268

CONGENITAL DISTORTIONS.

applied to the ground in these cases being small, it becomes
inflamed and excoriated; besides which, a greater sensa¬
tion of weakness is experienced, owing to the constant
tendency to increase of inversion, whereas in the highest
grade, the inversion having attained its maximum, a firmer
bearing is obtained. The act of locomotion with increasing
age becomes more laborious. I have known many per¬
sons thus affected who have walked twenty or thirty miles
in a day; but it usually happens that so great a- sore¬
ness results from one day's exercise, that the individual
is compelled to rest for several days afterwards. Occa¬
sionally the callosity on the dorsum ulcerates or sloughs,
the tarsal bones become exposed, affected with necrosis,
relief having been often sought in amputation. Within
the last three years (1843) amputation has been performed
in this metropolis for removal of T. varus, in cases in which
ulceration did not exist. I shall be enabled to prove to
you that no case of T. varus ought to be amputated, un-

Fig. 107.

Adult congenital T. varus aggravated by use.

T. VARUS : SECONDARY CHANGES.

269

The subject of fig. 107 viewed posteriorly.

less such an amount of disease of the tarsal hones should
exist as would render amputation in a well-formed foot
necessary. One foot only may he affected.

[The figs. 107 and 108 illustrate one of the secondary
alterations of congenital varus, the folding of the sole re¬
sulting from use of the limb. The particulars of treatment
of this case were published in Treatise on Club-foot, 8fc.,
Appendix, Case XXIII.]

T. varus is attended with inferior development of the
entire member; this is more striking in the parts below the
knee. Sometimes this deficiency is not perceptible at birth,
hut becomes evident as the age of the individual increases.
Its extent at birth, as well as the severity of the deformity,
depend, in my opinion, upon the earliness of the period of
intra-uterine existence at which the deformity arises. As
in extra-uterine life spasm and paralysis partially arrest
growth and induce atrophy, so in the foetus this circum¬
stance results; and it follows, that the later the period at

270

CONGENITAL DISTORTIONS.

which the foetus becomes affected, the less arret de deve-
loppement the members generally will present. You will
readily understand that as, in childhood and adolescence,
a greater or less intensity of muscular contraction will pro¬
duce a corresponding severity of deformity; so in the uterus
the severity of the cause will, in a great measure, deter¬
mine the -grade of deformity. But it should he further
remarked, that in proportion to the earliness of the period
of infancy and adolescence at which a deformity arises, the
more readily the hones and ligaments yield to the displacing
power of the muscles. From analogy, therefore, it may be
inferred that, as at an early period of embryonic existence
the bones and ligaments possess little capability of resist¬
ing displacement, the earlier the muscles are excited to
abnormal activity the more severe will be the deformity,
and the arrest of development of the bones and other
structures of the affected members. In considering this
explanation of the intra-uterine origin of club-foot, you
will remember the fact of the muscles being characteristi¬
cally developed in utero earlier than the passive tissues, the
bones, ligaments, and cartilages. The muscles are de¬
veloped between the third and fourth month of gestation,
which corresponds with the existence of T. varus in four-
month foetuses, several of which I have anatomically ex¬
amined. In corroboration of this view of the origin of T.
varus, I may also mention the fact of the earlier develop¬
ment of the flexor and adductor than of the extensor and
adductor muscles. This fact will tend to explain the
greater frequency of T. varus than T. valgus. Congenital
talipes is sometimes accompanied with deformity of the
knee; this may be slight, and for a time elude observation,
or it may consist of slight inversion (as in fig. 104), the pa¬
tella (often very small) being situated too near the outer
margin of the limb, the biceps femoris slightly contracted,
and the flexion of the knee impaired as regards its direc¬
tion. In other cases more severe deformity of the knees,

CONGENITAL VARUS : MORBID ANATOMY. 271

sometimes complicated with derangement of the motion of
the hip, exists. Complete flexion of these articulations
may be present; the case then presents the greatest resem¬
blance to spastic non-congenital universal contractures (see
Lecture IX.). Other deformities may coexist.

Morbid Anatomy .—The greater part of that which has
been written on this subject appears to have been derived
from investigations of the feet of individuals who had long
availed themselves of the imperfect use of their limbs, and
in which the deformity had been aggravated from friction
and pressure.* The anatomy of T. varus can only be

* Some portion of that which has been written on the morbid anatomy
of varus has rather retarded than advanced the subject, inasmuch as few
authors have studied it in infantile subjects, although so essential, as the con¬
dition of the limb becomes at a later period much affected by continued action
of the dynamic cause of the distortion and by external agents. It will be
presently shewn, that many of the published dissections have been made on
adult subjects; and that the assertion of Scarpa, that the opinions derived
from dissections of the feet of adults would be as numerous, and differ as
much, as the feet dissected, is partially correct. Some appear to have con¬
jectured the internal arrangement of the bones merely from the external form
of the foot. It may also he remarked, that many of the authors hereafter
quoted have not stated whether the case examined was congenital or other-

The various opinions of the best authorities may be arranged in three
classes, and stated as follows, viz.

1. That the primitive formation of the bones is unnatural and incomplete.

2. That the bones, being originally perfectly formed, become injured and
distorted by causes independent of the formative process, viz. by pressure
occasioned by the foetus drawing the limbs into unnatural positions ; by an
improper situation of the foetus in the uterus j or by certain ligaments be¬
coming elongated, and the articulations distorted, from contraction of some
of the muscles and relaxation of others.

3. That, whatever may have been the condition of the bones bn the occur¬
rence of distortion, the act of walking displaces and injures them.

Glisson and Camper* were of opinion that varusj* arose from deformity,

* The author has not consulted the original work of Camper, which is in the Dutch
language, and entitled On Shoes, and the Evils occasioned by them. He has followed the
statement of Scarpa.

t In this summary the designation of the disease adopted by the respective authori¬
ties quoted, is employed, except in the expression of the author’s own opinions, when
the disease is denominated Talipes varus.

CONGENITAL VARUS.

272

determined with accuracy from the inspection of infantile
examples of the deformity, as well as adult ones. Hypo¬
thesis supplied the place of observation ; for, as some pa-

or even destruction, of the astragalus, and that the affection was consequently
incurable. Blumenbach* attributed the principal cause of varus to an un¬
natural shortness of the neck of the astragalus. Naumhurgf and WanzelJ
considered this bone to be distorted and displaced. Briickner§ combats the
opinion of the dependence of varus on a partial luxation of the tarsus. Scarpa|)
ascertained the existence of only slight deformity of the individual bones, and
that the os scaphoides, os cuboides, and os calcis, were displaced ; whilst the
astragalus was the least affected, and was invariably more or less completely
situated within the articular cavity formed by the tibia and fibula.

Jorg^f dissected two feet affected with varus: one, of a man aged sixty
years; the other, of a boy aged thirteen. In the former, the shaft of the
tibia was twisted anteriorly and outwardly, so that the internal malleolus,
which was smaller than natural, presented forwards ; while the external mal¬
leolus had receded. The articular surface of the inferior extremity of the
tibia had undergone so great a change as to be scarcely recognisable, being
adapted to receive the astragalus, which was so distorted as to resemble the
segment of a sphere, the remains of its round head being directed outwards,
and the posterior part turned inwardly ; the whole being rotated on its per¬
pendicular axis, and inclined forwards and downwards. The ginglymoid arti¬
culation of the ankle was consequently converted into a ball-and-socket joint.
Observation demonstrates that this conversion of the ginglymus into an im¬
perfect enarthrosis is the result of attrition (usure). The part corresponding
to the round head was not invested by the os scaphoides; the tuberosity of
the os calcis inclined inwardly, and its anterior process outwardly ; the entire
bone was rotated, so that the external margin presented downwards, and
the inferior margin inwardly. The os naviculare had advanced towards the
internal malleolus, and its internal extremity had become raised. The
position of the os cuboides was altered, so that its external portion was

* Geschichte und Beschreibung der Knoehen des menschlichen KSrpers: Gottingen,
1786, p. 440.

t Abhandlung- Von der Beinkrummung, von J. S. Naumburg, 8vo: Leipzig, 1796.

J Dissertatio inauguralis medica de Talipedibus Varis, auctore D. M. Wanzel: Tu¬
bing. 1798. Wanzel bad been affected with Talipes varus, and described the successful
plan of treatment he underwent in Switzerland.

§ Ueber die Natur, Ursachen und Behandlung der einwarts gekrfimmten Fiisse.
A. Bruckner: Gotha, 1796.

II Memoria chirurgica sui piedi torti eongeniti dei fanciulli, e sulla maniera di cor-
regere questa deformita, di Antonio Scarpa, 4to: Pavia, 1803. The drawing of the arrange¬
ment of the tarsus in Talipes varus, contained in Scarpa’s work, corresponds in all mate¬
rial points with that published in these Lectures, fig. 43.

IT J. C. G. Jorg fiber Klumpffisse, und eine leichte und zweckmassige Heilart der-
selben: Leipzig und Marburg, 1806, pp. 15-23.

MORBID ANATOMY.

273

tbologists assumed that the deformity depended on malfor¬
mation of the bones, they concluded that very extensive
changes in form and structure of these must exist. I am

applied to the ground. In the other case related by Jorg, the deformity
had reached the highest degree; hut the form of the individual hones being
unaltered, the description of the dissection corresponds with the opinions of
Scarpa. Clossius* describes this as likewise the case in one of the feet of
a man stated to be affected with varus in both extremities. In the other
foot, wherein the external deformity was greater, the round head and neck
of the astragalus were directed inwards and downwards, being flattened on
their internal surfaces ; the superior trochlea of the astragalus was altered in
its position, so that a considerable portion of its superior surface was not
opposed to the tibia, this bone having caused the formation of a new arti¬
cular surface on the posterior part of the body of the astragalus; and the
external surface of the trochlea, by protruding anteriorly, was not in contact
with the articulating surface of the external malleolus. Clossius further
relates, that the os scaphoides was connected in the most perfect manner
with the three cuneiform bones, but that it almost touched the internal mal¬
leolus.

Collesf concluded, from two dissections of varus (the one a child of five
years, the other a youth aged eighteen), the existence of several grades of
varus, and that distortion of the individual bones resulted from their displace¬
ment, and the injury arising from walking. In the former, many of the
muscles had assumed the colour of adipose tissue, but retained their fibrous
structure; the tendons of the tibial muscles were disproportionably long,
and, in consequence of the deformity, had swerved from their natural direc¬
tion. The internal malleolus was situated more forward than the external
malleolus by upwards of an inch; the superior surface of the trochlea of the
astragalus was divided by a transverse ridge into two portions, which he con¬
sidered would have presented a serious obstacle to the replacement of the
foot. The os scaphoides was drawn inwardly from the round head of the
astragalus. The other case presented less deformity ; but he concluded that
the oblique position of the tarsal joint, and the altered form of the astragalus,
were the primary causes of the distortion.

MackeeverJ investigated the anatomy of three cases of congenital distor¬
tion in infants : he found that the tuberosity of the os calcis touched the
fibula, and that the os naviculare was in contact with the internal malleolus,
and adherent by strong bands of fibrous tissue; on division of which the
foot was readily restored to its natural position. The tarsal bones differed
but little from the normal state; the muscles were of the ordinary bulk, and

* Ueber die Krankheiten der Knocken: Tubingen, 8vo, p. 270.

t Colles’ Dublin Hospital Reports, vol. i. p. 184.

t Edinburgh Medical Journal, vol. xvi. 1820, p. 220.

274

CONGENITAL VARUS.

satisfied, from perusal of several professed descriptions of
the anatomy of a club-foot, that the authors’ ideas were
derived from inspection of the living foot, and not from

the tendons of tlie usual length. In those situations where the bones had
come into unnatural contact, the surfaces were smooth, somewhat resembling
a natural articulation.

Palletta,* * * § finding the internal malleolus deficient in size, concluded this
to be the cause of the foot being drawn inwardly by the adductor muscles.
In the dissection of an infant six days old, he found that the os scaphoides
was not applied to the round head of the astragalus, but had been drawn
inwardly beneath the internal malleolus ; the neck of the astragalus also in¬
clined inwardly, but the trochlea was properly placed between the malleoli;
the remaining bones of the tarsus followed the direction of the os naviculare.
He found a similar alteration in the arrangement of the tarsus of a child
twelve months old, and alludes to the approximation of the tuberosity of the
os calcis to the external malleolus.

The researches of Delpech,f although valuable with respect to the pa¬
thology and treatment of the disease, add but little to the information pre¬
viously acquired on its morbid anatomy.

Cruveilhier states ,% that in his dissections of varus he observed the
atrophy of the muscles to be more complete than that of the bones. In a
female aged forty-one years, the nerves distributed to the muscles were much
reduced in size, the neurilema being nearly the only portion remaining; the
tibial arteries and veins were reduced to one half the ordinary size, and no
branch distributed on the muscles had admitted any^of the coloured wax with
which the arterial trunks had been injected; the whole of the muscles, with
the exception of the internal portion of the gastrocnemius externus, had un¬
dergone adipose transformation; the tendons were very slender, that of the
gastrocnemii being developed to only half its natural size. A smooth and
oval surface was formed at the extremity of the internal malleolus, by which
the tibia was applied to the internal surface of the os calcis; the opposing
surfaces were invested with cartilage. (A reference to fig. vi., plate 3, of Cru-
veilhier’s work, shews the inward inclination of the os naviculare: a general
correspondence exists between his representations of varus and fig. 43, p. 135,
of these Lectures.) He considers the unnatural form of the bones of the
tarsus in congenital varus to arise prior to ossification.

Lob§ published a description of the tarsal bones of an adult female affected
with Talipes preserved in the museum at Bonn. The alteration of the articular

* Exercitationes Pathologic®: Mediol. 1820, p. 138.

t Chirurgie Clinique de Montpellier: Paris et Montpellier, 1823, p. 200.

t Anatomie pathologique, livraison ii. 1830.

§ Dissertatio inauguralis de Talipedibus Varis: Bonn®, 1830.

CLUB-FOOT : MORBID ANATOMY. 275

dissection. The first great step in the elucidation of the
morbid anatomy of Talipes varus was the demonstration by
Scarpa, that of the several bones of the foot, the astragalus

surface of the astragalus was in his opinion sufficient to have prevented the
restoration of the foot; the upper part of the os calcis, which is rough in the
normal state, presented two smooth surfaces covered with cartilage, which
were continuous with the trochlea of the astragalus ; so that, from the extreme
state of extension in which the foot had been retained, the os calcis entered
into the composition of the ankle-joint. The os naviculare had gone inwardly
from the round head of the astragalus, followed by the os cuboides, leaving a
space between itself and the anterior part of the os calcis. (Compare this
description of the changes in position of the bones with figs. 43, 110, and
111, of these Lectures, with which it corresponds.)

Tourtual,* convinced of the importance of the study of the anatomy of
varus at an early period of existence, examined the feet of an anencephalous
seven months’ foetus thus affected. The navicular and cuboid bones were
rotated on their axes, and with the astragalus were partially displaced; the
posterior surface of the latter articulated with the tibia, instead of the superior
surface, resulting from the extended position of the foot. The round head
of the astragalus inclined somewhat inwardly-; its superior trochlea, which
appeared longer than natural, presenting forwards and inwards. The former
and the anterior articular surface of the os calcis were prominent, and were
simply covered with the skin and aponeuroses.f The os scaphoides touched
the internal malleolus ; and, contrary to the testimony of Scarpa, Delpech,
Jorg, Duveraey, and Chelius, Tourtual found the posterior tuberosity of the os
calcis drawn towards the fibula upwards and outwards. The tendon of the
anterior tibial muscle, in consequence of the inward yielding of the fore part
of the foot, was twisted around the anterior angle of the tibia, and became
inserted into the first cuneiform bone, after having passed behind the malleo¬
lus internus, instead of in front.J (Compare figs. 43, 109, and 110, of these
Lectures.)

* Zweiter anatomischer Bericht: Munster, 1832.

t In both feet of a nine months’ hemieephalous foetus, affected with the severest
grade of T. varus, the author found the round head of the astragalus and the articular
surface of the anterior extremity of the os calcis presenting downwards, and situated im¬
mediately beneath the-skin.

t The author has never yet, in infantile eases, been able to perceive that this tendon
was directed behind the malleolus internus; but has observed its course over the anterior
angle of the tibia somewhat higher than natural; after which it became unnaturally in¬
clined inwards towards the internal cuneiform bone, into which it was inserted by a band
Of unusual width. The inferior extremity of the tendon was, therefore, more internally
situated than the malleolus internus, resulting from the altered position of the front part
of the foot. See fig. 109. In both feet of a hemieephalous foetus the whole of the muscles
and tendons were much smaller than in a well-formed foetus, having been with difficulty *
dissected; the entire limb was well encased in adipose tissue, precluding, from its bulk.

276

CONGENITAL VARUS.

is the least displaced. It had been previously asserted,
amongst other misstatements, that the astragalus was lux¬
ated.

As the opinions of Scarpa generally agree with the results of the author’s
experience, they are here detailed with less minuteness than their importance
otherwise deserved. The conclusion at which Scarpa had arrived was, that of
the entire tarsal bones, the astragalus had suffered the smallest degree of dis¬
placement; which alone proved the possibility of curing infantile T. varus.

The determination of this point
109, was of infinite moment, the

confined their anatomical oh-.
MM ■■Ilf servations to the feet of indi-

\lliiI ' IL « if viduals who had passed the

/JEaMi the accuracy of Scarpa’s con-

--—-ip elusions. But Palletta, Mac-

keever, and Tourtual, describe

View of foot affected with infantile congenital varus, of the obstacles to flexion or
the integuments and fascia only having been thrown abduction of the foot, would
back, in order to shew the abnormal direction of haye pr e Ve nted its articular
some of the tendons. , „ ...

trochlea' performing its func¬
tions in thetibio-tarsal cavity; although several trifling changes in the bone
are related by the latter anatomists. The essential anatomical characters of
varus are described at p. 279 of these Lectures. In every instance which the
author has examined, the anterior extremity of the astragalus inclined in¬
wardly, but only to such an extent as to cause the external surface of its
trochlea to project from the ankle-joint somewhat farther than the internal
surface. Fig. Ill shews that the round head is twisted inwardly apart from
the general inward direction of the bone.

any suspicion o:
of the muscles

muscles. This imperfect development

MORBID ANATOMY.

277

The accuracy of Scarpa’s opinion has been disputed by
succeeding writers; but the result of my observations of
more than thirty specimens of varus, from subjects of dif-

Weis (De Anat. Patholog. Fed. Equini et Vari: Arhusii, 1842, p. 10)
found the extensor digitorum and peroneus brevis muscles comparatively ill
developed.

Mr. W. Adams {Transactions of Pathological Society , 1852) has described
the alterations in the form of the tarsal bones which he met with in two cases
of infantile varus. His description confirms the author’s opinion of the
immaterial changes which the bones undergo previously to use of the part.
Mr. Adams has witnessed absence of the ext. long, digitor. muscle. The
author has never observed greater deficiency of this than other muscles.
He has even found the long and short extensors well developed (see fig. 109).
The author believes that the deficiency or atrophy and degeneration of
muscles is in a precise ratio to the extent of the deformity, and the earliness
of the period of uterine existence at which the deformity is produced. The
fact of hypertrophy of part of gastrocnemii, observed by Mr. Adams, is an
important contribution to the pathology of varus, since it shews another
analogy with con-congenital Talipes, in which sometimes hypertrophy of the
contracted muscles exists (see p. 14 of these Lectures).

The deviation of the os calcis is next in extent to that of the navicular
bone; in a sound foot, the round head of the astragalus is principally sup¬
ported by the inferior calcaneo-scaphoid ligament, which sustains a consider¬
able portion of the weight of the body; but in severe varus the anterior
extremity of the os calcis is forced inwardly as far as the round head of the
astragalus, and occasionally beyond it, taking the office of the calcaneo-
scaphoid ligament; and the posterior tuberosity of the os calcis is conse¬
quently directed outwardly towards the fibula. It is possible that the two
following symptoms occurring in varus may have deceived several authors,*
and induced the opinion that the posterior tuberosity of the os calcis had
yielded inwardly :—-first, the apparently inward inclination of the heel, owing
to the length of the inner margin of the foot being so much diminished, and
rendered hollow by the front part being drawn both inwardly and backwards.
Secondly, the appearance of the anterior extremity of the os calcis on the
external aspect of the foot; which is likewise a result of the inward twisting
of the navicular, cuboid, cuneiform, and metatarsal bones (see fig. 30, p. 108).
The extent of separation of the cuboid bone from the os calcis varies consi¬
derably, being sometimes insufficient to form tbe triangular interval described
p. 279 ; but in foetuses affected with the highest grade of deformity, denuda¬
tion of the anterior extremity of the os calcis by the os cuboides is some-

See Duval, Traits pratique du Pied-bot: Paris, 1839, p. S4,

278

CONGENITAL VARUS.

ferent ages, is, to confirm the opinion of Scarpa, and add,
that I have examined no preparation of varus in which
each of the three facets of this bone, which articulate with
the tibia and fibula, has not been in partial contact with
the appropriate surface of these bones. The confirmation
of Scarpa’s opinion, and the results of my own observa¬
tion, have been of the utmost importance in enabling me
to determine, from pathological anatomy, the propriety of
undertaking the treatment of the highest grade of T. va¬
rus, namely, that fepresented figs. 105 and 107.

The empirical tendency of art to advance from the
treatment of the simple to the more complicated defor¬
mities would alone have confirmed my previous supposi-

times witnessed, its entire articular surface being simply covered with the
integuments.

It is remarkable that the more correct opinion, viz. that the bones are
primarily unaffected, corresponds with that of Hippocrates; but whether Hip¬
pocrates considered the causes of displacement to be resident within the limb,
or to arise from external influences, cannot from his language be determined:
“ There is more than one variety of club-foot; the most of them being not
complete dislocations, but impairments connected with the habitual mainte¬
nance of the limb in a certain position” (Opus cit, p. 632). By the de¬
taining power alluded to, he may have understood either external mechanical
agents, or the unequal action of certain muscles. Hippocrates has been
quoted as the supporter of the theory of varus being produced by uterine
pressure (Memoire sur I'Etiologie du Pied-bot, par F. Martin : Paris, 1839),
upon the strength of distinct observations to this effect contained in a treatise
on generation, incorrectly attributed to Hippocrates. (Translation of Hip¬
pocrates, by De Foes, vol. ii. p. 395.)

The summary of the investigations of the anatomy of varus may be con¬
cluded with the words of Scarpa :—“ None of the tarsal bones are actually
dislocated ; but in addition to the state of extension of the ankle-joint, they
undergo rotation on their axes, and the astragalus suffers less alteration of
position than either of. the tarsal bones.”

B. Bell* alludes to Talipes in the following manner: “ Limbs may be
distorted in various ways and by different causes, either from morbid state of
bone, or from contracted state of muscles, or both. The malformation of the
bones is the effect of rickets ; but the most frequent cause of distorted limbs
is contraction of flexor muscles of the leg and fore-arm.”

* A System of Surgery, by Benjamin Bell: 1788, vol. vi. p. 281.

MORBID ANATOMY.

tions, and have demonstrated the possibility of rectifying
the position of the foot in cases of this description. The
astragalus being the only hone of the tarsus which enters
into the composition of the ankle-joint, explains the im¬
portance of determining its anatomical condition.

An examination of these
drawings (figs. 110 and
111) will illustrate the po¬
sition of the tarsal hones
in complete varus. The
os calcis is drawn up¬
wards ; the tibial articular
facets of the astragalus and
its round head are exposed
upon the dorsum of the
foot; but the scaphoid,
cuboid, cuneiform, and me¬
tatarsal bones, are not mere¬
ly drawn towards the sole,
but also inwards and up¬
wards [and sometimes

backwards], SO that the Position of bones in infantile congenital varus.
innermost point of the na- The comparatively posterior situation of
r anterior tibial tendon is shewn.

vicular bone touches the

internal malleolus, and has an articular surface formed on
it, occasioned by contact and friction. The superior or
external surface of the os cuboides is somewhat separated
from that of the os calcis; whereas the plantar surfaces of
these two bones are turned towards each other, leaving a
space between them externally. The course of the tendons
of the muscles situated upon the front of the leg is conse¬
quently much altered. Those of the tibialis anticus, ex¬
tensor proprius pollicis, and ext. long, digitorum, more par¬
ticularly the first of these, are deflected so much internally,
after passing over the ankle-joint, as to serve by their
action to increase the deformity in the living subject.

CONGENITAL VARUS.

Such are the essential anatomical characters of Talipes
varus. According to the severity of the deformity, either
of the characters before
mentioned may be more
or less distinctly traced.

It is unnecessary to de¬
scribe in detail the non-
essential phenomena met
with in the examination
of these feet, such as os¬
seous vegetations, and
evidences of former ca¬
ries of the surface of
those hones which have
suffered from pressure
against the earth; and
some other still greater
malpositions of the tarsal
hones, likewise the occa¬
sional result of external
pressure and injury from
walking, or from wear¬
ing improperly adapted mechanical instruments.

An attentive study of the anatomy of Talipes varus will
further confirm the opinion of its origin, that the muscles
are the parts primarily involved, and that the displacement
of the hones is entirely secondary. If the bones were
simply arrested in their development, or if they had been
injured by external causes, and the contraction of muscles
were but secondary, the bones would not bear so precise
a relation to the action of the respective muscles inserted
into them. The preparations from which the drawings are
taken shew that the shortening of the gastrocnemii corres¬
ponds to the elevation of the heel, whilst the adductors and
remaining muscles on the posterior and internal surfaces of
the ankle have drawn the navicular, cuboid, cuneiform, and

Fig. 111.

Anatomical relation of adult congenital severe
varus. The extreme retroversion of the front
part of the foot and doubling under of the lesser
metatarsal and cuboid bones, as well as the in¬
version of the round head of the navicular with
the cuneiform hones, are well shewn. The
greater portion of the round head of astragalus
is deformed, deficient in polished surface, owing
to disuse and attrition against the shoe.

conjoint powerful action-of the gastrocnemii and the other
muscles enumerated, have bent the foot at the summit of
the tarsal arch, drawn its component parts asunder, whilst
the connecting ligaments were yet soft.

Treatment .—The treatment of congenital varus is not
simply an empirical process of straightening that which is
deformed, hut an interesting subject of study, in which
the etiological and pathological facts effectively direct the
resources of art. The principal antagonists are the gas¬
trocnemii and the adductors ; and as a result of the malpo¬
sition, the ligaments and fasciae are variously affected, some
being shorter, others longer than natural. (In many cases

CONGENITAL VARUS.

the tissues of the sole are involved.) The practitioner has
to determine whether these obstacles to straightening shall
he removed by tenotomy or by mechanical extension.

The length of time required to effect a cure is of less
consequence in children than in adults. The circumstance
of children not comprehending the object of the treatment,
or the necessity of the pain or irksomeness to which they
are subjected — the susceptibility to the injurious effects
of continued disturbance of rest peculiar to their age —
their liability, when the general health is disturbed, to be
affected by any of the prevailing infantile epidemics,—are
reasons why children cannot, on the whole, bear as unre¬
mitted an application of mechanical instruments as is occa¬
sionally necessary in adults; it is therefore fortunate that,
with reference to the degree of resistance to be overcome,
the facility of effecting a cure is so much greater at this
period.

Many cases occur in which the deformity may he
nearly or entirely removed for the moment by pressure with
the hands; but others exist in which the tension of the
contracted muscles is so great, particularly of the gastro-
cnemii, that although the adduction and rotation of the foot
may, as long as the pressure of the hand is continued, be
more or less completely overcome, yet the greater part of
the elevation of the heel remains. The former afford
greater prospect of success by the sole application of me¬
chanical means of cure ; but in many of the latter removal
of the deformity will not be obtained without division of
the Achilles or other tendons, although the treatment may
be commenced within a few weeks after birth, and be per-
severingly continued throughout the whole period of child¬
hood.

Experience alone can enable you to determine, with any
degree of certainty, whether the cure of Talipes in an infant
is obtainable by the application of mechanical means; but
in the formation of an opinion you will be guided by the

TREATMENT.

extent to which the deformity can be removed by the hand,
and the nature of the resistance offered by the muscles.
If the active spasmodic state of the muscles still appear to
exist, accompanied with considerable structural shortening,
notwithstanding the foot may for a moment be reducible
to its natural form with the hand, you should be less san¬
guine of a. permanent cure by means of instruments.

. I recommend* for several reasons, that in every case
of Talipes,* the treatment of which can be commenced
previously to the age of six months, the cure should be
attempted by the application of mechanical means, provided
your efforts will be seconded by the parent. Many cases
are curable without operation. Interruptions in the treat¬
ment are, from various causes, more liable to occur during
the earliest months of existence. If the treatment be me¬
chanical, a temporary suspension of the extending power
exercised by the apparatus is not fatal to the ultimate
success of the plan; but if, after the performance of the
operation at so early a period, a necessity arises for discon¬
tinuing the wearing of the extending apparatus, a loss of
time occurs, during which the divided tendon firmly re¬
unites, the cure being as distant as prior to the operation,
and a repetition consequently required. When the opera¬
tion is perfectly successful, and the foot entirely reduced
to a proper form by the application of mechanical contriv¬
ances for a few days or weeks, it still is necessary to retain
the foot in its newly-acquired position by means of appa¬
ratus until the child arrives at an age to walk (or even
afterwards) ; for, in consequence. of the tendency to con¬
traction occurring in the medium which unites the divided
tendon [and sometimes owing to the persistence of mor¬
bid action in the muscular fibre], the deformity will pro¬
bably be reproduced if this precautionary measure is neg¬
lected.

Another reason for considering the propriety of treating

* The exceptions are cases like fig. 104, which from the outset, at the
age of two or three months, require operation.

£84

CONGENITAL VARUS.

infantile cases without division of tendons is the objection
which, on general grounds, may be made to the perform¬
ance of any operation, however simple, during the earliest
months of existence.

The most favourable period for the division of tendons
in infantile cases of Talipes is a few months before the
time when the child may be expected to make the first
attempts to walk—about the age of six or eight months,
until which time, in cases of Talipes varus, mechanical
apparatus should be used to turn the toes outwardly, re¬
ducing the deformity to the condition of Talipes equinus;
in the latter affection, whether primary or so reduced, de¬
pression of the heel may be judiciously attempted, which,
if not wholly successful, will at least prevent increase of
the deformity. If, by means of the operation and subse¬
quent application of mechanical instruments, the reduction
of the foot to a proper form be effected at the period
when the child evinces a disposition to walk, he will rapidly
acquire strength and activity. The act of walking will
then, to a great extent, guard against the recurrence of
the deformity; and the use of any mechanical apparatus
may 7 within a short time be discontinued. But the cure
of infantile Talipes varus cannot be so completely effected,
if, during the earliest months of life, the application of
mechanical apparatus, calculated to maintain the toes in a
straight line with the leg, by overcoming the twisting in¬
wards and rotation of the foot, be neglected. The de¬
velopment of the internal malleolus and the neighbouring
parts having been impeded by the adduction of the foot,
or the child having walked, by which the external parts of
the tarsus have suffered from attrition, also add to the
difficulties.

The plan which, in private practice, I pursue in infants
under the age of six months affected with varus curable with¬
out operation is simple, and which, with proper directions,
can be entrusted to parents and nurses. It consists of the
application of a smooth and narrow roller-bandage around

MECHANICAL TREATMENT.

28 5

the foot and leg, from the extremity of the toes to the knee,
interposing along the inner margin and sole of the foot,
and the posterior and internal part of the leg, a quantity of
cotton wadding, to protect those parts from pressure. The
limb is then firmly and evenly bandaged in a tin splint,
—the entire attention being first directed to the removal
of the inward tendency of the toes, and the reduction of
the T. varus to the condition of T. equinus. The limb,
when properly secured in this splint, is exposed to pres¬
sure in the direction the toes would maintain if held out¬
wards with the hands in the position of T. equinus, the
inside of the metatarso-phalangeal articulation of the great
toe and inside of the superior extremity of the tibia
being the fixed points, towards which the bandage presses
the ankle and tarsus, tending to overcome the unnatural
curve presented by the deformed foot.

Much care is requisite in the application of the splint,
as pressure in an improper direction might, at this early
period of the development of the tissues of the foot, pro¬
duce a permanent displacement or flattening of the bones
of the tarsus. Several cases of T. varus which had been
for years under ill-directed mechanical treatment, and in
which there existed secondary alterations of form, attribu¬
table to pressure improperly exercised at an early period,
have presented themselves to me. The hack of the splint
should be applied to the posterior part of the leg and foot,
and the raised part should extend along the inside of the
leg and inner margin of the foot, or occasionally along the
opposite side, for the purpose of varying the pressure or of
changing the action of the splint. Should the splint have
slipped around the leg, it must be immediately reapplied.
The whole apparatus should also be removed on every
occasion that the bandages become soiled by the infant,
and immediately replaced; for if the foot be permitted to
remain a few hours without the restraint of the splint,
more advantage would during that period be lost than had

CONGENITAL VARUS.

been gained during its application for treble tbe length
of time.

As soon as the contraction of the adductor muscles of
the foot and the inward inclination of the toes is observed
to be considerably diminished, and particularly if, on the
removal of the apparatus, the toes are not drawn inwardly,
the splint may be advantageously exchanged for another,
the foot-part of which is bent more upwards. This should
be applied in the same manner as the previous one, by
which means a constant stretching of the contracted gas-
trocnemii may be maintained. Should these yield,, splints,
the foot-parts of which are bent to a still greater degree,

Fig. 113.

Three of the series of tin splints recommended in the text. No. 1 is adapted for the left
foot, and No. 2 for the right, whilst the elevation of the heel continues considerable;
No. 3 has the foot-part much inclined towards the leg, and is consequently fitted for a
case far advanced in the process of cure. Between Nos. 2 and 3, others, with the foot-
parts at gradually increasing inclination towards the leg, maybe employed to complete
the series.

may be employed, until perfect flexion of the ankle is
obtained.

On the infant attaining the age of six months, or if the
treatment be postponed until this period, a more efficient in¬
strument (see fig. 114) may be advantageously substituted.
But as in the application of splints the rectification of the
position of the foot must be attempted gradually, the foot-
piece a b, fig. 114, must be screwed to such an angle with
the perpendicular spring c, as to correspond with the ob¬
tuseness of the angle which the foot forms with the leg.

One of the more prominent causes of failure in the
treatment of club-foot is the injudicious haste with which

288

CONGENITAL VARUS.

excessive pressure, and from friction occasioned by the en¬
deavours of the child to disengage the limb.

Whether the cure he conducted with or without an

to the deformity—those of abduction and rotation outwards. If the reader, acquainted
with the anatomy and pathology of Talipes varus, will put his sound foot into one of
these instruments, and endeavour, whilst his foot is there, to give it the form ofT.
varus, he will feel how strongly the springs oppose his attempts; in fact, he will he
convinced that if he wore the instrument sufficiently long, his sound foot would be
converted into a deformity resembling the opposite of T. varus, namely Talipes valgus.
It is at the point intermediate between these two diseases that the practitioner must
stop in the treatment of the former—at the position of the foot intermediate between
adduction and abduction—at the point corresponding to the natural position.

Fig. 115.*

The preceding apparatus as applied.

* Success in the employment of any particular instrument is as much
the result of the manner of application as of its peculiar efficiency. A few

MECHANICAL TREATMENT.

289

operation, it is of the utmost consequence to apply the
necessary apparatus in such a manner that the repose of
the child may not he disturbed, or uneasiness and constant
fretfulness induced, which might interfere with its appetite
and amusements. The welfare of a child so much depends
on the necessary quantity of sleep being obtained, that the
action of the apparatus should he almost imperceptibly
increased; and although restlessness may at first he pro¬
duced, the child will thus become accustomed to its appli¬
cation. The cure of Talipes would he dearly purchased
at the sacrifice of general health; hut the careful progress

simple directions for the application of that lepresented in fig. 114 may not
be inappropriate. A thick woollen stocking, or an elastic cotton bandage,
should first be applied; if the foot is not well encased in adipose tissue, a
portion of cotton wadding may be laid over the instep. The ankle-band/,
detached from the strap i, should be buckled around the leg above the mal¬
leoli ; holding the shoe-part of the instrument in the left hand, the heel
should be placed with the right in the shoe, and secured by means of the
straps gg firmly against the inside a (fig. 114). The heel should be pre¬
vented from rising by fastening the strap i to the back part of the ankle-band
/; and the spring c, by means of the circular band e, formed of thin metal and
properly padded, be applied to the outer side of the leg. This will effect a
change in the ankle-joint similar to that ensuing in the wrist when the hand is
pronated. The inner margin of the foot being then directed to the ground, in
opposition to the natural tendency of T. varus, the toes should be drawn as far
outwardly as can be effected without pain, by means of the padded strap h
attached to the spring d ; lastly, the ankle should be bent, by turning the screw
l, with a key constructed for the purpose, as far as the tense tendo-Achillis
will permit. As the screw l acts through the female screw Jc, which is fixed as
a rotatory rivet upon the spring c, and t (fig. 115) is merely a stud through
which the smooth part of the screw existing between the termination of the
thread and the knob s can move freely forward and backward, a certain degree
of motion of the ankle-joint is allowed in the act of walking, tending to
increase its flexion, whilst the position of the screw l prevents the heel from
becoming elevated. If the spring c act in directing the inner margin of the
foot to the ground too powerfully and painfully, a piece of tape or a small
strap may be attached to the inside of the band e, which is applied around
the leg below the knee, and fastened to a buckle on the inside of the foot.
This will moderate the action of the spring, which can be increased in the
daytime and diminished during the hours appropriated to rest.

%yu

CONGENITAL VARUS.

with extension of the contracted parts, and the removal of
the apparatus once or twice daily, will uninterruptedly ad-

MECHANICAL APPARATUS.

291

The foot-board of Stromeyer with some additions, useful during the treatment of Equint
varus. It is constructed for the right foot. The letter a is a heel-piece, of brass o

: passed through

vance the restoration of the foot, provided it he curable
without operation.

In this institution I frequently recommend the opera¬
tion of tenotomy in very young infants, sometimes so early

CONGENITAL VARUS.

as the age of six or eight weeks.* The circumstances that in
these cases determine me in the selection of the operative
in preference to the simply mechanical method are, either

Apparatus for Extreme varus contrived by the Author. — In the treatment of the worst
cases, figs. 105 and 107 for example, by the apparatus, figs. 114 and 115, he found
that when by means of the screw l the foot was bent, the long spring c, owing to
the resistance it encountered, became twisted upon its longitudinal axis, and ceased
to act as a lever. In order to obviate this difSculty, the lever a, fig. 118, was added
to the inside of the spring. As represented in the drawing, this lever is furnished with
two hinges opposite the ankle, by means of which it can be adapted to the generally
curved form of the external part of the tarsus and ankle, whilst the sole-piece is at the
same time made vertical, and adapted to the vertical position of the sole. After the
foot and leg are secured in the foot-piece, and the lever is fastened around the leg,
the spring 5 is brought into a line with the lever, and secured to it above, either
at a suitable distance by means of tape, or if its full power is wanted, by the stud at
upper end of a. This apparatus has borne the test of ten years’ service, and with
the aid of tenotomy has effected restoration of many of the most severe cases of adult
varus. It requires the same straps as at figs. 114 and 115.

* Dr. Evory Kennedy, previously to 1840, performed the operation in an
infant four weeks old. See paper by Mr. Halpin, on division of T. Achillis,
in Dublin Medical Press, January 1840.

INDICATIONS OF TENOTOMY.

the extreme severity of the deformity, in which experience
demonstrates the absolute necessity of the operation ; or
that, from the inability of parents to devote the requisite
attention to the treatment, I am aware that whatever time
may be employed for the purpose, whatever pains may be
taken, the result will be unfavourable. Even with the aid
of the operation, the children of parents more favourably
situated cannot be restored without their zealous co-opera¬
tion. The same difficulty attends the treatment, among
the very poor, of all diseases, the relief of which cannot
be effected by the vis medicatrix naturae. In the treat¬
ment of Talipes the abnormal efforts of nature tend con¬
tinually to frustrate the best-directed exertions.

Many cases, then, present themselves, in which, among
the less dependent classes of society, you may satisfactorily

It will be remarked, that in the preceding modifications of Scarpa’s shoe the flexion or
extension of ankle is effected by means of a male and female screw. The author has
always found that it is not desirable to retain a deformed foot under treatment for
days, weeks, or months, in an inflexible instrument. In figs. 114 and 115 a certain
motion is permitted by means of the smooth part of the screw from s to t (fig. 115).
Through this permitted mobility manual movements of the part, valuable adjuncts to
treatment, can be effected. These movements become more indispensable when the
. patient can be allowed to take exercise. To facilitate this object, the author contrived
the adjusting-screw and quadrant represented fig. 119. Passive movements when
seated, and active bending during exercise, can be effected by this arrangement to any
extent. It is the simplest, least expensive, least liable to need repairs, of any of the
contrivances he has seen. For adjusting straps, see fig. 114.

CONGENITAL VARUS.

recommend mechanical means, but which, among the very
poor, you will treat by tenotomy, as a means of expediting
the recovery. It is unnecessary to discuss the relative
merits of the two methods. Tenotomy is not appropriate
to cases remediable by instruments. If you are in doubt,
try the mechanical plan; but if, when the age of walking
approaches, the patient is not sufficiently restored to per¬
mit the free application of the foot to the ground, and the
performance of the natural movements, tenotomy should
be no longer postponed, as the act of walking on the foot
in an improper position for a single week will certainly
aggravate the deformity. • This remark applies as well to
walking with the aid of “ irons,” into which instrument-
makers place children in order to enable them to support
themselves. If the effect of the “ irons” is not to cause
the child to tread quite evenly, they are worse than useless.
They serve only to hide the increasing deformity.

[In the treatment of foot-deformities, other apparatus
may be occasionally employed. Stromeyer’s foot-board
is ingeniously adapted to T. equinus, T. equino-varus, and
equino-valgus (see figs. 116 and 117), and presents an im¬
portant advantage for hospital practice, that it is inexpen¬
sive, and may serve for many patients in succession. In
extreme congenital T. varus, the modification of Scarpa’s
shoe (fig. 118) is of utmost service. It is capable of adapta¬
tion to severest cases. The movement represented fig. 119
may be substituted for any of the contrivances enumerated.
Its advantages consist in the freedom of movement of ankle
in the desired direction permitted to the patient during the
act of locomotion.]

As club-foot essentially depends on unnatural shorten¬
ing of the muscles of the calf and of the anterior and pos¬
terior tibial muscles, you might, when, at any age, the
operation is resolved upon, a priori conclude that section
of each of these parts is indispensable. If tenotomy were
resorted to simply as a means of removing the presumed
spastic state of the muscles, if its modus operandi were

TENOTOMY : STAGES IN TREATMENT.

295

dynamic, it would follow that every muscle involved should
be severed. But the operation is often requisite as a
simple means of elongating a contracted cord; its effect is
mechanical. It is difficult to determine in every case of
T. varus whether spastic action of muscles, or mere struc¬
tural shortening of their fibre, maintains the deformity.
You may, therefore, on 'principle, determine to divide the
largest of the tendons, that which by its anatomical ar¬
rangement offers the largest share of resistance,—the tendo-
Achillis for example,—and complete the cure by mecha¬
nical elongation of remaining tissues. But if, in cases of
average severity, you perceive that the anterior and pos¬
terior tibial are very tense, the fibres of the patient robust
and unlikely to yield to mechanical treatment, you will
determine to divide these also. In numerous instances the
flexor muscles of the toes and the plantar fascia are con¬
jointly affected, and consequently division of those within
reach, the flexor longus pollicis, plantar fascia, or even the
abductor pollicis, should be effected.* After every section
many tissues remain for elongation by mechanical treatment.

The operative treatment of severe T. varus in youths
and adults may be advantageously divided into two stages.
Owing to the slowness of restoration in extreme cases (as
at figs. 107, 105), the treatment often occupying six [to
twelve] months, it is proper to divide, in the first instance,
the tendons and other structures which adduct the foot,
and devote attention to its eversion so as to reduce it to
the condition of T. equinus, and subsequently to sever the
tendo-Achillis and depress the heel; the object being, in
the first instance, to reduce a complicated deformity to a
more simple form. A common splint, bandaged on the
outer side of the limb, often proves the best mechanism

* Mr. Martin Coates attributes to the plantar fascia and muscles too large
a share in the maintenance of varus. His Practical Observations on Talipes,
Salisbury, 1810, were particularly valuable, by shewing the advantage of sever¬
ing the fascia in question.

CONGENITAL VARUS.

for this purpose, or the splint (fig. 120) may be employed.

Splint occasionally applicable, in the reduction of
the severest grade of T. varus. The letters a a
represent a strong wooden splint, having a cir¬
cular hole at the part applied to the malleolus
externus; b b, an india-rubber air-cushipn,
placed between the splint and the outer side of
the leg. The straps with buckles marked c
serve to secure the splint firmly against the
limb; d is a steel spring, the power of which
should depend on the strength of the ligaments
and other tissues which it may be requisite to
elongate; e is a padded strap passed around the
front part of the foot, the lengthening or shorten¬
ing of which diminishes or increases the traction
exercised by the spring. The foot and leg should
be bandaged, to prevent the occurrence of swell¬
ing.

The depression of the internal
edge of the foot and of the heel
can he effected by the apparatus
(figs. 114, 118, 119). By these
means the most severe congenital
T. varus, in patients even of thirty
years of age [and upwards], may
he entirely removed. The after¬
development of muscles and ac¬
quisition of strength of limb may
be facilitated by the general measures so often enumerated
whilst speaking of other deformities.

[Several modes of dividing the posterior tibial tendon
in T. varus have been proposed. Thus Stromeyer’s plan
is that described in these Lectures at p. 93. It is only
applicable to adults, or to cases in which the tendon is
prominently visible.

Weis*' and Yelpeau divide it at its insertion into the
navicular bone, the knife being inserted so as to meet the
tendon about an inch (in the adult) below and in front of the
inner malleolus. To avoid wounding the plantar artery, it

* De Tenotomia Talipedibus applic. C. Weis : Havnise, 1844-; and British
and Foreign Medical Review, vol. xxi. p. 171.

Fig. 120.

OPERATION FOR INFANTILE VARUS.

297

is recommended that the knife should not he carried fur¬
ther in during the section of the tendon than is absolutely
necessary. * This plan is equally inapplicable to infants.

“ Dr. JAvdes plan for dividing posterior tibial tendon in
the infant ”*—To perform this operation on the left foot,
it is necessary that the little patient should be laid upon a

* The successful division of the posterior tibial tendon in the infant con-
stitutes an important epoch in the history of tenotomy applied to the cure
of varus. The above operation is acknowledged to fulfil the conditions of
celerity and safety, and is now generally adopted in this country. By this
method and by that of Stromeyer the long flexor is often at the same time
divided, which constitutes an advantage.

At the period of publication of his Treatise on Club-Foot, &c. (1839), the
author had only operated the posterior tibial in adolescents and adults, in whom
it is visible or easily felt, by the method of Stromeyer. From this period to
1842 he was accustomed in children above the age of twelve months, from the
difficulty of accurately feeling the outline of the tendon owing to relative
fatness of legs compared with the size of the tendon, to expose the tendon by
an incision in the integuments three quarters of an inch in length, and divide
it upon a director. Having about this period witnessed suppuration in a
limb ending fatally, in which a tendon had been severed after exposure, the
author relinquished this departure from subcutaneous tenotomy. To meet
the necessity of dealing with the posterior tibial tendon by tenotomy in the
same manner as the anterior tibial and tendo-Achillis, all of which the author
had from 1837 taught as coadjutors in production of varus—division of it by
exposure in fat children being abandoned—his pupil and subsequent colleague
Mr. Tamplin proposed to divide the posterior tibial by effecting a puncture
into the sheath of the tendon with a stilette and canula; and after withdrawal
of stilette, introducing through-the canula a blunt-pointed knife. The idea of
thus dividing the tendon from before backwards towards the artery was novel,
but both unsuccessful and unsafe. After withdrawal of the stilette, the canula
could not easily be held within the aperture made into the sheath, the blunt-
pointed knife could not then be passed into the sheath, and in the act of
plunging a stilette and canula from before backwards between the tendon and
the tibia, there was risk of penetrating too deeply, and of inflicting a punctured
wound upon the posterior tibial artery and nerve, or of transfixing the tendon
itself. Mr. Tamplin, as well as the author, tried this proceeding two or three
times, and was compelled to abandon it. The author perceived the weak
points of that operation, and profited by the suggestion to divide the tendon
from before backwards, rejected the stilette and canula, substituted a small
scalpel for making an aperture into the sheath, and had the knife b, fig. 122,
made by Ferguson, as an improvement upon the tenotome of Bouvier, with

298

CONGENITAL VARUS.

table of convenient height, and that a competent nurse
steady the arms and hold the right knee out of the way
of the operator.

The annexed drawing repre¬
sents the normal anatomy
of the parts interested in
this operation:— a, tendon
of tibialis posticus passing
behind the internal mal¬
leolus, and enclosed in its
proper sheath; the line (ct)
corresponds to the point
described as the proper
/ place for its division; b,
tendon of tibialis posticus
d appearing from beneath
the flexor communis digi-
torum; c, tendon of flexor
communis digitorum im¬
mediately behind tibialis
posticus; d, origin of flexor
m communis digitorum from
tibia; e, tendon-Achillis;
/, origin of solaeus from
j tibia; g, posterior tibial
e nerve midway between
tendo-Achillis and flexor
9 digitorum communis; h,
a posterior tibial artery close
c to the nerve; ''ii, tibia; l
* represents the fascia which
covered the deep layer of
muscles, but is now re¬
flected forwards, and fas¬
tened to the tibia with a
pin: the drawing shews
its insertion- into the edge
of the tibia; m, layer of fat
and skin reflected.

An assistant,
having a few small
dossils of lint, a

Fig. 121.

which to divide the tendon, satisfied that, if he should wound the posterior
tibial artery, it would in all probability be by a division, and not by a punc¬
ture. Experience has justified this proceeding—that if the artery be entirely
severed, the disposition of the divided ends to contract, aided by moderate
pressure, prevents haemorrhage or false aneurism. The author’s method was
first published in the British and Foreign Medical Review , 1844, vol. xxi.

MODE OF SEVERING POST. TIBIAL TENDON. 299

bandage, and tbe necessary knives witbin reach, takes his
place by the side of the patient and holds the thigh, whilst
the operator, seated in front, endeavours to feel the slight
prominence of the posterior tibial tendon with the thumb
of the left hand, during the time he is either abducting
the foot or inducing the child voluntarily to move the
ankle-joint.

For all practical purposes, however, it is quite sufficient
to make out the inner edge of the tibia, about a finger’s
breadth above the lower end of the inner malleolus; or
should there be any difficulty in defining this ridge of bone
in consequence of the fatness of the limb, the careful in¬
sertion of the knife exactly midway between the anterior
and posterior borders of the leg , on its inner aspect, will
be a true guide to the position of the tendon, not forgetting,
as anatomy teaches us, that an incision made a little in
front of this line might wound the internal saphena vein
and nerve ; and if made behind it, would run the risk of
dividing the flexor communis digitorum instead of the ti¬
bialis posticus ; or the knife might even pass posterior to
the former tendon, and if carried deep enough, might wound
the artery and nerve without touching any tendon what¬
ever.

Having thus determined the exact situation of the
posterior tibial by one or all of these methods, a sharp-
pointed knife (as represented in fig. a) is passed through
the skin at about a finger’s breadth above the inner mal¬
leolus, according to the age of the child. It must be made
to penetrate steadily down, perpendicularly to the surface,
to a depth varying from a third to a quarter of an inch.
In doing this, it is necessary to be quite sure of sufficiently
opening the fascia covering the posterior tibial and common
flexor tendons, otherwise when the probe-pointed knife is
passed in (as will be described in the next stage, of tbe
operation), it may either hitch against this dense unyield¬
ing structure, or glide over its surface behind the deep

300

CONGENITAL VARUS.

layer of muscles, instead of passing through the opening
in front of them.

In order, therefore, to accomplish the free division of
this fascia of the leg close to its insertion into the edge of
the tibia, and likewise the more delicate and proper sheath
of the posterior tibial tendon beneath, the sharp-pointed
knife should be passed to the depth above recommended;
the handle must then be elevated so as to depress the
point of the blade; that is to say, the instrument should
be used as a delicate lever, the centre of motion being
the skin, which may be pressed upon gently by the back
of the knife; and in this way an opening of the requi¬
site size can be made in the fascia at the bottom of
the wound, without the risk of enlarging the external
aperture.

Having thus far accomplished the operation, the sharp-
pointed knife is withdrawn, and a probe-pointed one (fig. b)
is to be passed down the same track of wound through
the skin, superficial fascia, layer of adipose tissue, deep
fascia, and lastly the proper sheath of the tendon, and be
now inserted a little further in, so as to get well between
the posterior tibial and the tibia. "When satisfied from the
sensation communicated to the knife that the bone is on
one side and the tendon on the other, all that remains to
be done is to turn the edge towards the tendon, giving the
knife a slight cutting motion, while at the same time the
assistant firmly abducts and depresses the inner border of
the foot.

A distinct sensation of something having suddenly
yielded can be perceived at the time of the division of
the tendon; but if the case should have been previously
operated on, this feeling may be very slight in consequence
of the adhesions existing between the original wound of
the tendon and the adjacent parts.

As soon as this peculiar jerk is detected by the assist¬
ant, he should immediately relax the foot and apply a

SECTION OF POST. TIBIAL TENDON IN INFANTS.

small dossil of lint over the
wound, holding it there with
the forefinger during the divi¬
sion of any other tendons. If
the artery is supposed to be cut,
either from the sudden escape of
florid blood, or from the mark¬
ed blanched appearance of the
foot, it will only he. necessary
to apply a graduated compress,
and to roll firmly a figure-of- f
eight bandage upon the foot'
and ankle. This, however,
may require to he loosened in a
few hours if the colour of the
toes shews any indication of
strangulation. If the operator
is not ambidexter, he will find,:
in the operation for dividing:
the posterior tibia! tendon of
the right limb, that he had
better stand on the left side of
the patient with his back to
the patient’s face, whilst the
assistant sits down in front and
holds the thigh with one hand
while he steadies the toes with
the other.

Taking, then, the mesial
line or the inner aspect of the
leg at about three-quarters of
an inch above the inner mal¬
leolus as the true position of
the tendon, the sharp-pointed
knife is to be inserted with its
back towards the sole of the

Ftg-

CONGENITAL VARUS.

foot. It is thus made to divide the skin and deep fascia
in the same way as was explained when cutting the left
posterior tibial tendon. After this instrument is with¬
drawn, the probe-pointed knife may now be used to finish
the operation, which, in all other respects, agrees with the
section of the corresponding tendon on the opposite side
of the body.

Whilst these pages were passing through the press, re¬
peated dissections of the ankle, in order to shew the relative
position of the artery and nerve to the tendons about this
part, suggested that the sharp-pointed knife (fig. a) might
he passed to the necessary depth between the tendon and
bone (as recommended in the first stage of Dr. Little’s
operation); and that by turning its edge the posterior
and tibial tendon might easily and safely be divided during
the abduction of the foot, thus reducing the operation from
one a, deux temps to a single proceeding. Trial of this
method upon both feet (Extreme Varus), in an infant aged
six weeks and in a boy aged seven, without wounding the
artery, and with Dr. Little’s confirmation of the fact, that
he had never felt the posterior tibial tendons yield more
readily, justifies the recommendation of this simplified
operation to the notice of surgeons. (Gowlland.)

The division of the anterior tibial tendon in Talipes
varus should follow the section of the posterior tibial; the
patient being in the same position, and the assistant still
holding the limb, and pressing his finger upon the lint
covering the puncture already made above the ankle.
The operator should feel for the most prominent part of
the tendon over the joint, somewhat nearer the malleolus
than in the normal foot, and insert a sharp-pointed knife
(fig. c or d), with its flat surface towards the tendon ; and
having passed it well beneath, he should turn the sharp
edge towards the tendon, whilst the forefinger of the left
hand is pressed gently over the part, to warn him of the
approach of the knife to the surface.

DIVISION OF ANT. TIBIAL TENDON.

303

The assistant, who has been steadily abducting the
foot during the operation, gradually relaxes his endeavours
as he feels the tendon yield; and so soon as he perceives
the distinct snap which is the result of its complete divi¬
sion, he should immediately relax his hold, and apply a
small dossil of lint over the puncture. Division of T.
Achillis in infantile varus is accomplished after turning the
infant over on the abdomen as described p. 92.*

If the cases of congenital club-foot be classed under
three grades, all those of the first or slightest grade may
unquestionably, within a reasonable period, be cured by
well-applied mechanical treatment. Many of the second
grade will also yield to this method, although the treat¬
ment will necessarily be more tedious, perhaps scarcely
completed when the time arrives at which healthy children
usually walk alone, say twelve or fourteen months; whilst
the whole of those of the severest grade can only be reme¬
died, within a reasonable time, by operation. The author
would not, after the observations at p. 283, return to this
subject, if he did not believe that, however essential teno¬
tomy is in the above proportion of cases of infantile club¬
foot, it is unnecessary in the remainder of the cases; for
although the form of the member is by means of tenotomy
more promptly remedied, the function of the divided muscles
is often less completely restored. The author has witnessed
many instances of congenital varus successfully treated with¬
out tenotomy, by others as well as by himself, in which the
muscles of the calf attained almost the normal develop¬
ment ; whereas after tenotomy the muscles usually remain
much smaller than natural, and the calf disproportionably
high. He is too sensible of the value of tenotomy pro-

* Mr. E. Weight, surgeon to the Wokingham Union, Berkshire, in de¬
scribing (Medical Gazette , 1839) some interesting cases of Talipes operated
by himself, has proposed to term tenotomy the Thilenian operation, in honour
of Thilenius, who first determined to divide the tendo-Achillis as a therapeutic
measure.

304

CONGENITAL VARUS.

perly applied to disparage it; he desires only to offer an opi¬
nion that may stay the hands of an occasional over-zealous
operator. Useless, i. e . unnecessary tenotomy weakens
the muscular power of a limb which, without operation,
might have attained the normal development; whereas,
paradoxical as it may at ; first sight appear, the proper
application of tenotomy, by enabling the attendant to
effect a cure of a deformity proved by experience to be
otherwise irremediable, prevents the occurrence of atrophy,
which is the ordinary concomitant of uncured club-foot;
nay more, in proper cases the operator has the satisfaction
of witnessing a gradual augmentation of muscle. (British
and Foreign Med. Review, vol. xxi. p. 176.)

The completeness of recovery in the great majority of
the cases of congenital varus constitutes a perfect triumph
of art. Even in stubborn cases during childhood, if the me¬
chanical after-treatment be properly : attended to, repetition
of operation is rarely requisite. In the severest adult
cases, owing to the length of time occupied by the me¬
chanical treatment, it may be necessary to redivide the
ten do- Achillis once or twice; but the more frequent repe¬
tition of operation effected by Dieffenbach and Phillips*
is accounted for by the little attention directed to mechani¬
cal treatment by those authors.

During childhood congenital varus may be entirely
cured, without other traces of deformity than smallness of
the member, greater squareness of front of foot, and some¬
times less complete mobility of ankle-joint, the patient re¬
covering entire volition. When the case is unattended to
before adult age, the internal margin of the foot may never
be completely applied to the ground, owing to the impossi¬
bility in some cases of perfectly unfolding the os cuboides
from its inferior and rotated position in the tarsus; in other
instances, owing probably to the round head and neck of
the astragalus having become so much inverted in relation
* De la Tenotomie sous-cutanee, Ch. Phillips : Paris, 1841.

PROPER TIME POR REPLACEMENT.

305

to tlie remainder of the bone, that part of the undue
convexity of the tarsus outwards becomes irremediable.
Every year will doubtless reduce the number of adult cases
of .varus requiring treatment, so that the consideration
of any means of meeting the attendant difficulties may
appear superfluous. The author has usually found a most
efficient agent in a firm pad placed in the sole beneath
the os cuboides,. by which means, during instrumental
treatment, before and after locomotion is permitted, the
principal pressure of the instrument is directed against
the protruding bone. He has often thought that in in¬
veterate varus, such as figs. 105 and 106, the treatment
might well be commenced in robust subjects by ablation
of the os cuboides, which, in preventing the unrolling of
the foot, acts as the key-stone of the inverted arch. He is
of opinion, that by this means the treatment of certain
cases might be reduced from twelve months to six or eight
weeks.

Age sets no limit to the applicability of tenotomy; the
author has successfully treated adult varus at the age of
forty, and non-congenital equino-varus at fifty-four.

As an absolute rule, after tenotomy no replacement of
the part should be attempted until after the puncture has
cicatrised; and as a general rule, no sudden or rapid re¬
placement is proper until some days later. Much has been
written respecting the propriety of immediate replacement.
It is unnecessary in slight cases, and impossible in severe
ones (see p. 168). In slight cases, nothing is gained by it;
for if the position may be immediately rectified, the part
cannot be immediately used. The part should, therefore,
be gradually replaced whilst the tendon is consolidating
without the smallest pain at the severed part.

Stromeyer has suggested, that previously to operation
the patient should be accustomed to wear the replacing
instrument. This plan is desirable when the practitioner
is unfamiliar with the treatment of deformities; for he
x

306

CONGENITAL DISTORTIONS.

thereby becomes versed in the action and mode of appli¬
cation of the apparatus, and is rendered certain beforehand
of the appropriateness of the contrivance.

With reference to the choice of apparatus, Stromeyer
has rightly remarked, that every practitioner will select that
of which he best understands the action and mode of appli¬
cation. This sagacious observation explains also one cause
of the zeal with which each writer advocates his particular
appliance.

It cannot be too strongly insisted upon, that in a large
number of deformities, whether treated with or without
operation, expensive instruments are unnecessary. More
depends upon the tact, patience, and perseverance of the
practitioner than upon the apparatus employed. Common
roller bandages, tin, wood, or gutta percha, may, in inge¬
nious hands, supply the place of the most elaborate con¬
trivances (see p. 31).

It may sometimes happen that no instrument is avail¬
able, and the after-treatment require to be entirely con¬
ducted by manipulations. Thus an adolescent case of double
congenital varus was admitted into the London Hospital,
under the care of Mr. Critchett, which had been rejected as
incurable from another hospital on account of large ulcers
with necrosis of dorsum of each foot, induced by pressure
during the mechanical treatment after tenotomy. As the
unhealthy character of the ulcers depended upon want of
air and exercise, and the application of suitable instruments
was impossible, it was determined to repeat tenotomy, and
effect forcible manipulations of the members. Chloroform
was upon one occasion employed. By these means the feet
were gradually straightened, cicatrisation of the ulcers was
thereby favoured, and within three months the lad quitted
the hospital.

After congenital varus, as after acquired deformities,
retentive apparatus may be required : these for the most
part consist of jointed irons to support weak articula-

CONGENITAL CALCANEO-VARUS.

307

tions, and springs to assist the action of debilitated muscles
(see Appendix).

Congenital Calcaneo-varus.

A deformity which may be thus named is sometimes
present at birth. It consists of the inversion of the toes,
contraction and vertical position of the sole, and convexity
of dorsum of varus, without the elevation of the heel
which occurs in that deformity. Its cause is preponderat¬
ing action of the anterior and posterior tibial muscles —
through which the foot is thrown upon the outer margin
—and of the plantar muscles, in consequence of which the
hollowness of sole and convexity of dorsum are produced.
Prominence of round head of astragalus exists through the
navicular bone, and the front row of tarsal bones being
drawn inwards and towards the sole.

The deformity is never very considerable ; the author
has only seen it in one foot at a time. In some instances
the opposite member has been affected with ordinary varus.
The treatment consists in the removal of the preponderant
action of adductors and plantar structures by mechanical
treatment or tenotomy, according to age and amount of
deformity; the same rules for deciding being applicable here
as in treatment of varus (p. 283). The result of treatment
is less favourable than in ordinary varus. The instrument
figs. 65 and 66 may be useful in these cases.

Ordinary varus is sometimes converted into a deformity
resembling calcaneo-varus by division of tendo-Achillis
and removal of heel-elevation, and omission to remedy
the adduction and plantar contraction. For this reason
it is desirable to remove the adduction of varus either
simultaneously with, or even previously to, the relief of
the contraction of gastrocnemii.* It is, moreover, easier

* Duval (opus cit.) has proposed entirely to alter the nomenclature of
Talipes by terming ordinary varus Equino-varus, in consequence of elevation
of heel entering into the constitution of varus. This substitution of a new

CONGENITAL DISTORTIONS.

to remove the inversion of severe varus, and especially
the contraction of the sole, before the tendo-Achillis has
been divided; for the retracted gastrocnemii, when undi¬
vided, firmly hold the os calcis during the treatment di¬
rected to elongation of the sole (p. 295).]*

term, although scientifically indicated, is not desirable in opposition to the
usage of twenty centuries.

Duval considers that the distortion I have designated Calcaneo-varus
alone merits the name of varus. As congenital Calcaneo-varus is an un¬
common distortion, Duval would apply to it a designation universally given
to the most common of distortions, through which confusion would occur.
Less difficulty would arise from the adoption of his term Strephopodie
(ffrpetpw, to twist), as a generic term for foot deviations. But even this de¬
signation is unnecessary, Talipes being now generally employed in Germany
and England. Several French authors apply the term Kyllopodie (kvMAs,
bent inwards) to varus.

* It may be remarked as a contribution to the etiology of congenital dis¬
tortions, that the parents of children born with varus, for example, often
present uncommon convexity of tarsus without contraction of leg-muscles, and
without appreciable deformity, or they, and their fathers before them, have
been particularly accustomed to turn-in their toes. They have what may be
considered a small element of Calcaneo-varus or of varus, viz. unusual con¬
cavity of sole, probably due to some, unusual tension of plantar muscles, or
some undue tension of posterior leg-muscles. But in accordance with the
observed law in physiological pathology, that parental derangement is re¬
produced in the progeny in increased intensity, unless counteracted by an¬
other law which regulates the union of the sexes, but which it is unnecessary
to enter upon here; the child is born not simply with an affection dependent
upon slight undue tension of plantar or other muscles (as in the parent), but
presents increased disorder of nervous and muscular systems, severely in-,
volving muscles of the leg, as well as of the sole, and consequent varus. It
cannot correctly be asserted, that the fact of well-marked distortions being
hereditary is a proof of their dependence upon nervous and muscular systems,
and not upon mechanical influences in utero ; inasmuch as an hereditary ten¬
dency to abnormal size and site of the uterus, and consequent mechanical dis¬
turbance of embryo, may be supposed to exist.

The fact of augmentation of diseased action in succeeding generations
speaks more for the origin of deformities within the embryo.

LECTURE XYI.

Congenital distortions (continued)— Congenital Talipes valgus — T. equi-
no-valgus — T. calcaneo-valgus—Treatment of these deformities —
Universal congenital distortion of the lower extremities—Congenital
paralysis of the lower extremities —- Congenital luxations — Conge¬
nital distortions of the upper extremity — Club-hand — Valgoid de¬
formity of hand—Congenital wry-neck—Congenital deformity of the
spinal column—Congenital hypertrophy of muscles and other parts —
Malformations— Classification.

Talipes valgus is a much more rare affection than T.
varus. It may be regarded as the opposite state, and, like

Fig. 124.

Front view of a congenital Talipes valgus of the right foot of a boy aged four years, d a,
the outer edge of the foot raised from the ground; e, the great toe raised from the
ground, although the internal edge of the foot is directed towards it; 5, the internal
malleolus; and c, the internal extremity of the navicular hone, being the parts upon
which the patient walked.*

* When slight congenital valgus is not discovered until the child begins to
walk, it maybe confounded with slight rachitic or spurious valgus. If not dis¬
tinguishable by other signs, the existence of contraction, or deformity of the
great toe, will shew the case to be true valgus (from muscular contraction).

310

CONGENITAL DISTORTIONS.

it, consists of a threefold alteration of the position of the
foot; partial bending of the ankle, a&duction, and a rota¬
tion of the foot exist; but the rotation takes place in the
opposite direction to that in Talipes varus, as in T. valgus
the external edge of the foot is removed from the ground.
The rotation in a complete case of T. valgus is so great,
that the patient in the act of walking does not touch the
ground with any part of the sole of the foot, hut treads
entirely upon the inside of the instep and upon the mal¬
leolus internus, as in this model (fig. 124). In short, the
sole of the foot is directed completely outwards -and a
little backwards, the ankle is held in a state of semiflexion,
the anterior half of the foot (the metatarsus and toes) not
touching the ground.

A result of the destruction of the equilibrium of the
muscles of the foot, through the tension of the peronei, is
to expose the yielding tarsus of the infant to he bent be¬
tween the opposing anterior muscles of the leg and those
of the calf (see p. 170).* So long as the astragalus is pro¬
perly acted upon by the gastrocnemii and anterior muscles

Fig. 125.

* Congenital varus is sometimes converted into a valgoid deformity through
the injudicious use of mechanical means. The position of the toes is changed
from inversion, to eversion; but as the tendo-Achillis does not yield, the tarsus
bends in the middle, as already described, valgus taking the place of varus.

CONGENITAL VALGUS AND EQUINO-VALGUS. 311

of the leg, these muscles mutually balance in their action ;
but when, through the unnatural tension of the peronei,
the natural movements of the ankle are suspended, the
tarsus yields in the middle, both extremities of the foot
are elevated, the most inferior part of the tarsus being the
navicular bone.

Three opportunities only of anatomically examining
valgus have been presented to me. The subjects from
which the preparations were taken were full-grown foetuses.
In these, so far as the incomplete development of the
osseous structures enabled me to judge, the astragalus was
twisted in such a manner that the articular facet, which
ought to have been applied against the internal malleolus,
did not enter into the composition of the ankle-joint, but
was turned downwards; the navicular bone and calcaneum
followed the astragalus, and, together with the internal
malleolus, would have touched the ground by their inter¬
nal surface. The external edge of the os cuboides, and
fifth metatarsal bone, and external surface of calcaneum,
presented directly upwards; the latter, therefore, was in
contact with the external malleolus. The extremity of
this process could not be felt.

The peronei tendons, and the long extensor tendons of
the toes, constitute the principal obstacle to restoration ;
the tendo-Achillis is tense, and deflected outwardly through
the rotation of the os calcis.

Talipes equino-valgus .— This congenital deformity is
not very common : it precisely resembles, as respects exter¬
nal form, the non-congenital T. equino-valgus, arising from
articular disease, or from paralysis of the anterior tibial
muscle (see fig. 68, p. 169). If models of the same de¬
formity from paralysis and articular disease be compared
with those of which the origin is congenital, the identity
of form will at once be recognised. These congenital de¬
formities may often be successfully treated by mechanical
applications ; they sometimes resist this plan, and you may
be compelled to have recourse to tenotomy, as in T. varus.

312 CONGENITAL DISTORTIONS.

It is unnecessary to repeat here the circumstances that
may render the operation indispensable. It is only neces¬
sary to remark, that the tissues requiring section may he
the peronei, the extensor longus digitorum, and the tendo-
Achillis. The same apparatus recommended for club-foot
may he in these cases employed, with this important dif¬
ference, that as the object will be to induce inversion of
the toes, and depression of the outer edge of the foot, the
springs should be applied on the inside of the limb.

Another congenital distortion of the lower extremity
is T. calcaneo-valgus. In this affection (see fig. 127) the

Congenital Talipes calcaneo-valgus in an infanta few weeks after birth.

front part of the foot is elevated and abducted, through
the contraction of the peronei and extensor longus digi¬
torum being .combined with contraction of the anterior
tibial and extensor proprius pollicis muscles. As no con¬
traction of the gastrocnemii occurs in this deformity, the
heel is depressed. The extensors of the knee may be

CONGENITAL CALCANEO-VALGUS.

313

conjointly contracted, the movements of the articulation
impeded, and the patella imperfectly developed. This
deformity offers greater probability of cure by mechanical
means than either of the preceding congenital distortions,
as the powerful gastrocnemii assist by their action the re¬
placement of the foot; nevertheless I have been compelled
to employ tenotomy, and thus remove the resistance of
the peronei and the anterior muscles of the ankle. It is
more often possible to dispense with section of the latter
than of the former muscles. The apparatus recommended
in valgus is applicable in this
deformity. This congenital de¬
formity essentially differs from the
corresponding contracture (non-
congenitat) by the absence of pa¬
ralysis of the gastrocnemii (see

p. 160).

[It will be remembered that
although the author has attributed
congenital distortions, in general,
to deranged muscular action, yet
he has admitted the probability
that causes, similar to all of those
which act after birth, may act
within the uterus. A glance at
the representation of congenital
valgus, figs. 125 and 126, will con¬
vince the reader of the difficulty
of explaining the origin of a de¬
formity of that particular form in both feet from any other
influence than that assigned, viz.— perverted muscular
action—tonic or spastic contraction. The subject of figs.
125 and 126 was the same at the moment of birth, as when
three weeks later the drawing was taken. The same im¬
pression, with respect to etiological influences, might be
conveyed on an examination of fig. 127; but an examination

Fig. 128.

T. calcaneo-valgus at the period
of birth.

314

CONGENITAL DISTORTIONS.

of fig. 128, which represents one of the same feet, fig. 127, as
seen at the moment of birth, impresses the observer with
the conviction that so considerable an eversion of the outer .
margin, and approximation of the little toe and front part
of the foot to the leg, could scarcely be primarily effected
solely by muscular action. This deformity has more than
any other served to convince the author that, besides dis¬
tortions from muscular action, some congenital distortions
may be produced by pressure of some kind in utero.
Perhaps in this instance the etiological cause was impac¬
tion of a large child in a restricted space, the long me¬
chanical retention of the part in an abnormal position
having induced secondary preponderant action of the ab¬
ductors and anterior muscles of the ankle.]

General congenital distortion of the articulations of
the lower extremities occasionally occurs, and greatly re¬
sembles the universal non-congenital contractures formerly
described (see Lectures VIII. and IX.). The principal dif¬
ference between them is, that when congenital the general
development of the limbs is more impaired, the distortion
of the foot represents a more complete T. varus, and is
more frequently associated with distortion of the upper
extremity and wry-neck. I have witnessed many cases
of this nature. In two, unusually interesting, the children
were born with double T. varus, the knees rigidly flexed
to so great an extent that the feet were applied one over
the other against the nates. Abduction of the thighs was
impracticable: locomotion was impossible. The patients
always rested on the nates, the limbs remaining doubled
beneath this part (see fig. 129). When the universal con¬
genital distortion of the lower extremities is less severe,
the patient may, at different ages, be presented to you,
with the account that he has never walked, Or that locomo¬
tion has been effected with great difficulty and lameness.
You find on examination, the heels retracted, as in T. equi-
nus or in T. equino-varus; the knees flexed to a right

CONT. OF FLEXORS AND ApDUCTORS OF THIGH, &C. 315

angle; the thighs incapable of abduction, and flexed upon
the abdomen, with p . a ]2g

great hollowness of
the loins. Volition
exists in the con¬
tracted and uncon¬
tracted muscles, with¬
in the range of motion
permitted by the or¬
ganic or structural
shortening of the
parts. Remembering
the etiology of these
cases, and comparing
that with the actual
state of the parts, you
determine that the li¬
beration of the con¬
tracted parts, as far
as possible, by teno-

. i General congenital distortion of the lower extremities.

tomy and mechanical At birth ? he knees were J, ly drawn t0 the abdo l
elongation, will place men -

the members in a favourable condition for the exercise
of volition and acquisition of strength. Experience has
amply demonstrated the accuracy of the theoretic views
formed concerning the pathology of such cases. These in¬
dividuals may be enabled to walk in great comfort, although
the primary injurious influence exercised through the
nervous system on the muscles, and the atrophy arising
from the long-continued abeyance of function during child¬
hood, prevent complete re-establishment. Many such
persons, who had never walked, have been relieved by me
to the extent of fulfilling many of the ordinary engage¬
ments of civilised life. In some cases of this nature the
amount of facility of locomotion obtainable is less than in
others, in consequence of luxation of one or both hip-joints
caused by the incessant action of the flexor and adductor

316

CONGENITAL DISTORTIONS.

muscles. This constitutes one of the forms in which con¬
genital luxation of the hip occurs. An equally common
cause is congenital paralysis* of the whole or one set of
the muscles of the hip. Whether the equilibrium of
the muscles of the hip be destroyed by inordinate action
or by deficiency in one set, the remaining parts of the
articulation, the bones and ligaments, are imperfectly de¬
veloped ; hence the spontaneous luxation, as it is termed.
In truth, as you will now understand, no essential patho¬
logical difference exists between congenital luxations and
those which occur from altered muscular action after birth.
The practical difference arises from the earliness of the
period at which the congenital disturbance arises, and the
consequent adaptation during growth of the parts of the
articulations to the altered relations which they bear to
one another. The acetabulum and the head and neck of
the femur particularly suffer in their development.

[The intimate knowledge of congenital luxations pos¬
sessed in the present day (1853) has been derived from the
study of the anatomy of the subject in foetuses, as well as
from examination of the symptoms presented by these
affections at shorter or longer periods after birth. Con¬
genital luxations or sub-luxations, the latter being more
common than the former, often occur in many articula¬
tions at the same time in the same foetus, often symme¬
trical on both sides. They are common in foetuses which
have sustained evident derangement of nervous centres
(acephala, hemicephala); in short the etiological influ¬
ences of congenital luxation and of the common conge¬
nital distortion, club-foot, are the same. The difference
probably being, that whilst the disturbance of nervous and

* The existence of congenital paralysis has been, doubted. Since the
above was written the author has seen several cases. For example, he has
at present under treatment a young lady unquestionably born with distortion
of hands, arms, and legs. Mobility of lower extremities has been acquired,
but incomplete power of adduction of one thigh and total paralysis of adductors
of the other thigh exists.

CAUSE OF CONGENITAL LUXATIONS.

317

muscular system is in the one instance adequate to produce
only a certain amount of contraction of certain muscles and
deformity through the articular surfaces remaining in con¬
tact, the distortion is not much greater than that which
may he produced in voluntary action upon the part (club¬
foot, club-hand) ; whilst in the other instance, either from
the disturbing cause acting at a very early period of uterine
existence, before the distinct formation of articular liga¬
ments and cavities, the part is not only abnormally moved,
flexed, or extended, as the case may be, to the utmost
limit of voluntary action, or even beyond it, but the ar¬
ticular surfaces become positively luxated. As might be
expected, the structural shortening of muscles, ligaments,
and skin, and atrophy or arrested development of bones,
and of the organs generally, reaches a higher grade in
luxations than in the more common congenital distortions.

Of all the congenital luxations or sub-luxations, that
of the hip is the most frequent; but almost all the articu¬
lations may be enumerated as subject to this condition;
perhaps the order of relative frequency in the larger joints
is the hip, knee, wrist, elbow, and shoulder. In order to
constitute a perfect analogy between the lower and upper
extremities, the corresponding joints should be affected
with the same relative frequency. But the anatomical
form of certain joints, according to circumstances, im¬
pedes or favours displacement. Thus the comparatively
firmly packed articular surfaces of the astragalus permits
distortion (club-foot), but not luxation; whilst the slightly
articulated carpus is, before birth, more often sub-luxated
than merely contracted.]

It is unnecessary to detain you with a detailed con¬
sideration of the special operation applied [by M. Guerin]*
for relief of congenital hip-luxation. It rests upon insuf-

* Guerin’s elaborate and valuable Recherches sur les Luxations congeni-
tales: Paris, 184-1, conclusively brings congenital luxations into the category
of distortions produced by intra-uterine abnormal muscular action.

818

CONGENITAL DISTORTIONS.

ficient [or a too sanguine] application of the pathology of
the subject; and tenotomy, in this instance, has suffered
the abuse of most useful remedies, that of having been
somewhat indiscriminately employed.

The treatment of universal congenital deformity of the
lower extremities [with or without luxation or sub-luxa¬
tion] should be conducted on the principles of the treat¬
ment of congenital T. varus. Section of gastrocnemii,
adductors of the feet, the ham-strings, the adductor lon-
gus and brevis femoris, pectineus, rectus femoris, tensor
vaginae femoris, may, in suitable cases, be successfully per¬
formed. The remainder of the resistance to the move¬
ments of the articulations may be overcome by mechanical
appliances. I cannot dismiss this part of my subject with¬
out alluding to the greater improbability of cure of con¬
genital paralysis than of congenital spastic deformity. I
have never witnessed the recovery of power in muscles
paralysed before birth. Several of such cases have been
four or five years [ten to fifteen (1853)] under my ob¬
servation without amendment. This accords with patho¬
logical observation, that paralysis results from a higher
degree of disorder and disease in the nervous tissue than
spastic or irregular muscular action.

[The symptoms of congenital luxations or sub-luxations
are very similar to those of the displacements which occur
from articular disease (p. 66). The history—the co-exist¬
ence of other congenital deformities—sometimes the exist¬
ence of the luxation on both sides*—and the greater atrophy
and deformity of congenital cases distinguish them from the
non-congenital affections. Some congenital luxations rarely
find their representatives in acquired luxations. Of these
the luxation of the tibia forwards (fig. 131) is an example.f

* The existence of luxation of both hips is not an absolute proof of con¬
genital origin. The author described in his Treatise on Ankylosis a case of
double ankylosis from disease during the last stage of scarlet fever. Double
luxation may also occur from accident.

f F. Adams, LL.D., the learned commentator on Hippocrates (Sydenham

CONGENITAL LUXATIONS.

319

The slighter forms of congenital sub-luxation are
scarcely more than
ordinary contractures;
thus fig. 130 represents
one of the knees of fig.

129, extended as far
as possible by manual
stretching. The short¬
ening of ham-string
muscles, the deficiency
and tension of tegu¬
mentary structures,
and the partial dis¬
placement of head of
tibia into popliteal re¬
gion, are evident.

Sometimes the leg
is at the same time ro¬
tated outwardly, cor¬
responding with this
condition in false an¬
kylosis of knee (figs.

10 and 13).

Congenital luxation of knee, in which the tibia is drawn
forwards on the anterior surface of the condyles of the
femur, is a remarkable and interesting congenital deformity.
The knee is incapable of proper flexion ; on the contrary,
the leg is bent towards the front of the thigh, instead of
towards its posterior surface (see fig. 131). The quadriceps
femoris is tense and shortened, and prevents replacement;
and even the gracilis and sartorius, instead of assisting or¬
dinary flexion, tend to approximate the front of the leg to
the anterior surface of the thigh. Even in this abnormal

Congenital sub-luxations of tibia backwards. Short¬
ening of ham-string muscles and gastrocnemii. The
prominence visible on the instep was produced by
attrition against the ground in attempts to effect
locomotion upon nates, see fig. 129 ; and compare
the non-congenital similar paralytic affection, fig.
52, p. 151.

Soc. transl. of Hippocrates, vol. ii. p. 496) describes an interesting case of
accidental dislocation of the bones of the leg forwards upon the femur. Re¬
duction was easily affected.

320 CONGENITAL LUXATION OF KNEE FORWARDS.

position the biceps femoris asserts its influential presence,
by giving to the knee a certain de-
Fig. i3i. gree of inversion. The infant is

t sometimes said to have been born
with the feet one on each side of

The author, in every case which
has come under his observation,
has effected replacement by gentle
and continued mechanical treat¬
ment, and enabled the patient,
by means of mechanical support,
to walk well.

No doubt can exist that, by
congenital luxation of tma forwards continuance of this treatment and

and Upwards, originally incomplete . ...

in right limb, complete in the left, attention to manipulations, the

vered from the umbilicus down- he free from deformity, and dis-
wards. The thighs ludicrously look .. . . . . , .,

as if invested with short panta- pGHSG Wltll lHCCilcilllCcli 3.1 Cu Ab"
loons; and the flexure of the knee gence of pate H a has been errone-
in front, so unlike the normal ar- 1

rangement, reminds the observer OUsly Suspected in these Cases.]
of the articulation of the claws of ., 17 . , ,. n , i

the common crab. The drawing Congenital distortion of the Up-
represents the parts partially re- per extremity is comparatively
placed by the hand, for the pur- x • 1 1 _ m J

pose of shewing the front of the rare. I do not remember having

thlghs ' witnessed it in the shoulder* [of

living subjects]. It occurs in the form of abnormal flexion
of the elbow. The wrist and fingers are the most fre¬
quently affected. It occurs in several grades; sometimes
the development of the extremity is not generally impaired.
This constitutes club-hand, the position of the member and
the parts contracted being analogous to those of club-foot,
T. varus. In so-called club-hand—a term which should be
banished from scientific use—the pronators and flexors of
the wrist and fingers are contracted. Cases of this nature

* The majority of cases of supposed congenital luxation of shoulder
brought under the author’s notice have appeared to be the result of infantile
paralysis, displacement from weight of arm, and consequent atrophy.

CONGENITAL DISTORTION OF UPPER EXTREMITY. 321

admit of great relief. When slight, mechanical means may
entirely effect a cure, because an equal disparity between
the power of the flexors and extensors of the upper, as
between the extensors and flexors of the lower extremity
does not exist. The favour shewn the weaker muscles of
the arm by the application of a splint during the growth
of the member enables them to recover their just influ-
- ence; and although, if the right hand alone be affected at
birth, the individual may grow up left-handed, no distor¬
tion will remain in the weaker limb. When the case re¬
mains uncured throughout infancy and childhood, teno¬
tomy may be required. Section of pronator radii teres,
flexor carpi ulnaris, and of the palmaris longus, may suf-
• flee; sometimes, however, the flexor sublimis, and espe¬
cially the flexor longus pollicis require division. This con¬
genital distortion is more tractable than the corresponding
contracture (see p. 154). Sometimes the distortion is more
considerable, the ulnar side of the carpus, metacarpus, and
little finger, being in contact with the ulnar side of the
arm; sometimes combined with absence of one or more
fingers. From our knowledge of tbe pathology of distor¬
tions of the lower extremities, resulting from the greater
opportunities of observation, we should infer that as in
that situation as many forms of congenital distortion occur
as there are natural movements of the parts, so in the
upper extremity the same pathological fact should pre¬
sent itself. I have hitherto described the analogue in the
upper extremity to club-foot, viz. club-hand, and long ex¬
pected that, from analogy, I should some day meet, in the
upper extremity, with a distortion analogous to Talipes
valgus. I have not been disappointed; here is a model in
which the radial side of the hand is rigidly approximated
to the radius. Like T. valgus in the lower extremity,
this valgoid distortion of the wrist is more frequently than
club-hand associated with actual malformation of parts.
See Malformations (figs. 132, 140).

CONGENITAL DISTORTIONS.

[Fig. 132 is an example of congenital sub-luxation of
wrist forwards and outwards. The case
having reached adult age without attempts
at replacement, the infirmity was considered
irremediable, although a suitable mechani¬
cal contrivance effected much improvement
in position, and obviated much of the defor¬
mity. The patient had acquired very good
use of the member.]

Congenital wry-neck occurs combined
with other congenital distortions, or singly.
Its symptoms and treatment correspond
with the non-congenital corresponding de¬
formity. It yields to treatment more readily
than the non-congenital spastic or paralytic
forms (pp. 120, 137, 191).

[An affection of the neck occurs, in
^uo^lf wHst U for w hich, without disproportionate size of head
wards and outwards (as in hydrocephalus), a general laxity of
f tr°^ZT,cmsiJgde- the P art ex i sts 5 the head falls in every di-
ment development re ction (as in the new-born infant) long
ity of radius. Pos- after birth, apparently from absence of vo-
S'.CoT"; Mon, or more properly paralysis. It is
malformation re- probably sometimes congenital, but oftener
presented fig. ho. a neo-natal affection. See note, p. 122.

Division of the sterno-mastoid should be effected near
its origin, and requires the patient to rotate the head
forcibly towards the opposite side, in order to render more
prominent the contracted portion of the muscle. A sharp-
pointed knife (c, p. 301) is introduced through the in¬
teguments, about half an inch above the clavicle, with its
flat surface close upon the inner or outer edge of the
muscle, according to the side of the neck to be operated
upon. When the knife has gained the posterior surface
of the contracted part, it may either be withdrawn, and a
probe-pointed knife substituted; or if the border of the

Fig: 132.

CONGENITAL DISTORTIONS.

extent, it may be made to finish the operation by turning
its edge towards the contracted muscle.

In a fat subject, however, it will be better, after making
the necessary puncture through the skin and fascia sur¬
rounding the muscle, to pass the probe-pointed knife be¬
hind it, so that the possibility of wounding the subclavian
vein or transversal!s colli artery may be avoided.]*

The second subdivision of congenital deformities is com¬
posed of malformations. From the description I have given
you of the first subdivision, namely, congenital distortions ,
you are aware that, however great the distortion of parts
may be, to whatever extent the parts may be drawn from
their natural position by the active agents, the muscles,
no [essential] alteration in the form of the individual parts,
no deficiency, absence, or excess of parts, exists. It is
true that with the continuance of deformity the muscles
adapt themselves to the altered relation of parts, and be¬
come shortened, that the development of one part may be
impeded by the position of the member; but these consti¬
tute only secondary phenomena.

The subject of malformations is one of great interest
in a pathological point of view; but the distinctive cha¬
racter of the class being that of abnormal alteration of
form, from excess, deficiency, or aberration of parts, it
follows that they are less susceptible of remedy; indeed
they are, for the most part, irremediable. From this cate-

* Since the printing of p. 191, the author has been favoured by Mr. Brod-
hurst with the following description of an ingenious instrument, which he
has devised for the replacement of wry-neek : — “ It consists of a framework
of iron, which passes over the sternum and scapulae, and rests upon the shoul¬
ders. To this frame an upright piece is attached, which reaches to the atlas,
provided with three joints, moveable with cog-wheels. The first of these has
a forward and backward movement, to move the head from the sternum ; the
second, a lateral movement to stretch the muscle on either side ; and the
third opens and shuts a pair of blades, which grasp the lower jaw and fix
the head.” He has tried it successfully in an unequivocal congenital case.
Mr. Brodhurst has also made some interesting observations on the pathology
of non-congenital torticollis.

CONGENITAL MALFORMATIONS.

gory we must except those which consist of unnatural fis¬
sures, as harelip and hypospadias, curable by the plastic
art, imperforate states of mucous passages, as of the anus
and vagina, sometimes remediable by an artificial opening;
those instances of excess in which, as in the fingers or toes,
the superfluous part is removed by the technical process
of ablation.

Many malformations, from .their extent and severity,
are termed monstrosities , and but little of practical value
can be said concerning them.

[The pathological anatomists usually classify all con¬
genital deviations from the normal form under the head
of malformations. In these Lectures the author has con¬
sidered them under separate heads, because the idea of
malformation tends to suggest that of incurability, and
because a congenital distortion, except in etiological rela¬
tion, has little in common with a malformation or mon¬
strosity.

The following is the order of relationship of the dif¬
ferent congenital deformities, according to the amount of
departure from the normal form and the severity and
duration of producing cause : Distortions, luxations, mal¬
formations, monstrosities.]*

* Subjoined is Henle’s classification of malformations (Sommering, v.
Bane d. menschL Korpers, viii. 1).

Class I. Malformations in which one or more parts are either too small,
or altogether wanting. Monstra deficientia.

Order 1, Parts wholly deficient.

a. Affiorphus (Anideus, a priv., e?S os, form).

b. Consisting of a more or less rudimentary trunk.

c. Deficiency of inferior half of the body (Acormus).

d. Deficiency of superior half of the body (Acephalus).

e. Rudimentary head and spinal cord (Perocephalus, Paracephalus,

Pseudacephalus, Anencephalus, Hemicephalus, Microcephalus,
Spina bifida, Nosencephalus (vinos, disease), Thlipsencephalus
{6\iifns, pressure, crushing), Derencephalus (Sepr/, the neck, want
of brain and upper part of spinal cord). Deficiency of face
(Aprosopus, Microprosopus).

326

CONGENITAL MALFORMATIONS.

I have met with a singular congenital deformity of the
upper extremity, to which I may briefly draw your atten¬
tion. Here are models (exhibiting them ) of the upper ex-

f. Very general malformation (Perosomus).

g. Trunk defective, members perfect (Perocormus).

h. Limbs defective, head and trunk present, perfect or defective (Pe-

romelus, Gurlt; Ectromeles, Geoffr. St. Hil., eurpcceiv, to cause
abortion); Pbocomeles, <pu>Kri, a seal, bands and feet being
inserted immediately into the trunk ; (Hemimeles, Ectromeles,
Ectrodactylie).

Order 2. Dwarfed formations.

a. Nanosomus (vdvos, a dwarf).

b. Nanocephalus.

c. Nanocormus.

d. Nanomelus.

Class II. Coalitio partium. Symphysis.

Order 1. Fusion of the head.

a. Cyclopia, Monophthalmus.

b. Fusion principally of the lower half of the face (Monotia, Agnathus,

Otocephalus. See Geoffroy St. HiL for subdiv.).

Order 2. Fusion of the inferior half of the body, lower extremities (Syren
formation. Monopodia. Sympodia). Symeles, the legs and
feet being fused together, but otherwise perfect. Uromeles,
legs fused, single foot. Sirenomoles, legs fused without dis¬
tinct foot.

Order 3. Fusion of fingers and toes (Syndactylus, Gurlt).

Class III. Malformation from fissure; often connected with protrusion of
neighbouring contained organs from the fissured part, some¬
times consist of unclosed apertures.

Order 1. Head-fissures (Sehistocephalus, Gurlt j gxigt&s, cleft).

a. Fissure of cranium (related to Hemicephalus and Hydrencephalocele,

Otto; undoubtedly due to Hydrocephalus).

b. Fissures in the face, of the whole, or of the nose, upper lip, or

palate (Labium leporinum, Rictus lupinus); due to arrested de¬
velopment (caused by muscular retraction, Stromeyer).

c. Fissures of individual • parts of face: tuba Eustachii, tympanum,

tongue, iris, choroid.

Order 2. Fissures in the neck or trunk (Schistocormus).

a. In the neck (Fistula colli congenita), the remains of the bronchial

openings (the author has seen a case of this description, less well
marked than those described by Ascherson in 1832).

b. In the vertebral column (Spina bifida, from Hydrorachis).

CONGENITAL MALFORMATIONS.

327

tremities of a young woman. The right is perfectly sym¬
metrical and feminine, the left considerably above the
normal size, resembling more the limb of a blacksmith.

c. In the thorax and abdomen (fissura sterni, hernia pectoralis, Ectopia

cordis, Exomphalos, Prolapsus or inversio vesica; urinarise (see
Geoff. St. Hil. for further subdiv.).

d. In the urethra (Hypospadias, Epispadias).

Order 3. Internal fissures in lungs, spleen, liver, thymus, kidneys, ab
normal patency of ductus ven. arantii, duct. art. Botalli, fora¬
men ovale.

Class IV. Abnormal closure of openings, Atresia (&rpijTos, imperforate ).
Order 1. Atretocephalus (Gurlt). Congenital closure of mouth, nostrils
meatus audit, ext., eyelids, pupils.

„ 2. Atretocormus (Gurlt). Congenital closure of anus, urethra, va¬
gina, often combined with malformation ofintestine, uterus,&c.
Class V. Monstra abundantia.

Order 1. Of the whole body, the separate parts being more or less well
proportioned ; e. g. giants ; also the condition of Polysarcia.
The majority of this order scarcely belong to malformations.

,, 2. One or more parts are in excess, either from fusion of two
germs, or more probably the cleaving asunder of a single germ.

a. Supernumerary parts, the head and trunk being single, ossa Wor-

miana, double cranial bones, maxillae, tongue, teeth, coccyx,
ribs, muscles, fingers, and toes.

b. Supernumerary parts, head or trunk double or manifold (Monstra

duplicia, bigemina, trigemina,) through fusion or implantation
(Diprosopus, Dicephalus, Didymus, Symphyo-thoraco-gastrius
Hetero-didymus, &c.

Class VI. Situs mutatus.

Order 1. Of the heart, spleen, liver, intestine, &c.

,, 2. Of the course of blood-vessels, &c.)

„ 3. Of the change in situation of bones, congen. curv. of verteb.,

club-foot, club-hand from abnormal muscular contraction during
foetal existence.

Class VII. Hermaphroditismus.

Besides these classes are those pathological changes during foetal life which
are not included amongst malformations ; also the changes which the foetus
undergoes in extra-uterine foetation (Lithopadion), and the diseased condi¬
tions of placenta and foetal membranes.

These Lectures shew that many foetal conditions, included even by Henle
in the category of malformations, are through extended research brought into
the class of foetal diseases.

328

CONGENITAL MALFORMATIONS.

The left clavicle and scapula correspond with the abnor¬
mally large arm and hand. In infancy she was observed
to possess power of raising greater weights with the left
than the right; but at the same time it was noticed that
she did not possess equal flexibility of the member. Con¬
traction of the flexor and pronator muscles has gradually
increased, the movements effected by them being limited.
The elbow was rigidly bent about forty-five degrees. But
the peculiarity consisted in a hardness as well as hyper¬
trophy of the contracted muscles, viz. the biceps, and the
two masses of muscles arising from the condyles. The ten¬
sion of the pronators preponderated.

As the functions of the member were daily becoming
more limited, I effected tenotomy, by which, with some dif¬
ficulty, the limb was straightened, and in a-few months the
functions were restored. A tendency to recontraction ex¬
isted ; this was obviated by attention to daily manipulation
and use of the member. The hardness of the muscles in
this case exceeded the cartilaginous hardness and hyper¬
trophy sometimes observable in congenital wry-neck.

It is unnecessary longer to dwell upon this matter, but
refer to some remarks connected with it in the second lec¬
ture. The ancient explanation of such a case would have
been that the nisus formativus was in excess; but this is
the mere statement of a fact, and no explanation.

A frequent malformation exists either alone or com¬
bined with distortion, which, as it may be partially reme¬
died, so as to render the member serviceable for many
of the ordinary purposes of life, may be here described.
It consists of congenital atrophy of the leg and foot, with
malformation of the leg-bones. These appear to be fused,
so as in reality to consist of one bone only, presenting a
considerable curvature, anteriorly, as in the right limb of
this model (fig. 135). The deficiency of fibula is more
apparent inferiorly, where no malleolus externus is per¬
ceptible. Certain muscles, which are rudimentary, are con-

CONGENITAL MALFORMATIONS.

329

'union of right tibia and fibula, probable intra¬
uterine fracture of leg-bones, deficiency of toes.
Valgoid foot.

tracted, the gastrocnemii and the peronei; the foot is con¬
sequently everted, as in
T. valgus, and usually two
or three toes are deficient.

At the most projecting
part of the curvature of
the bone a dimple-like de¬
pression of the skin ex- ^
ists, the integument being
there more adherent to
the bone than elsewhere,
reminding the observer of
the cicatrix and promi¬
nence of tibia after bad
union of a compound frac¬
ture. Considering that
this malformation is often
combined with distortion
in other parts of the body, as in the left foot of the
model before you (fig. 135), and that muscular contraction
exists in the seat of the malformation, I am of opinion that
the origin of the malformation was similar to that of the
distortion; that through disorder of the nervous centres
both limbs were affected with inordinate muscular action ;
that in the right the convulsions of the member may have
been so considerable, and have occurred at so early a period
of intra-uterine existence, as to have occasioned mechani¬
cal injury and fusion, if not fracture, of the tender bones,
destruction of some of the metatarsals and corresponding
toes.* It is worthy of remark, in corroboration of this
hypothesis, that the deficiency of toes is on the peroneal
side of the member, in this model the fourth and fifth
being absent. The parts that have suffered are more
nearly in relation to the peroneal nerve. As the left foot

* Or the malformation may simply be termed defective development
through disturbance of nervous centres.

330

CONGENITAL MALFORMATIONS.

is not affected with, the highest grade of T. varus, and
little atrophy exists, I am of opinion that the affection of
this member was subsequent. The most interesting cir-

Fig. 136. Fig. 137.

Hypertrophy of some phalanges, atrophy of others; marks of circular compression, as if ly
umbilical cord.

cumstance in connexion with this malformation is, that in
a dozen or more examples the prominence of the bone,
the depression in the integuments denoting adhesion, have

Fig. 138.

Generally imperfect development of carpus, metacarpus, and phalanges. Several ter¬
minal phalanges and nails deficient.

CONGENITAL MALFORMATIONS.

33 1

invariably occurred in the same situation, so tbat the

Fig. 139. Fig. 140.

-- Valgoid malformation of left upper extre¬
mity ; d, the shoulder, e, the olecranon,
imperfectly developed. Absence of thumb, fusion of first and second fingers; w, in¬
ferior extremity of ulna. If, as already suggested, this he the advanced stage of fig. 132,
absence of thumb is readily explained. In the nascent state of the limbs in which these
malformations occur, the thumb would especially suffer from compression in the ab¬
normal flexure.

Fig. 141. Fig. 142.

analogues in the upper extremty.

332

CONGENITAL MALFORMATIONS.

cause of the curvature and fusion must in all cases have
been identical. It is difficult to comprehend that an ex¬
ternal cause, acting upon the foetus, would invariably influ¬
ence the member in a determinate manner. It is more con¬
sistent with the pathology of non-congenital distortions to
regard the injury of the bone as the result of muscular
action. It corresponds with the production of angular
curvature of the tibia in rachitis. The firmness of the
hone being impaired in this disease, the action of certain

Fig. 143.

Anterior view of uncommon malformation in which the valgoid form is perceptible. Fusion
of parts with deficiency. Notwithstanding the extreme departure from the normal
form, some of the principal parts of the normal foot could he indicated. Thus the
letter d marks the situation of the dorsum of the foot; t, the great toe and adjacent
toe fused together; h, the heel;.a t, the situation of anterior tibial tendon, which could
be voluntarily acted upon.

muscles becomes disproportionate, and suffices to bend this
organ, as formerly described in the lecture on rickets.

The malformation in question is susceptible of great
amendment; by section of gastrocnemii and peronei, with
subsequent mechanical treatment, a very useful member
is obtained. Sometimes both limbs are thus affected, and
often the knees and hips are involved. This malforma¬
tion of the tibia is sometimes combined with T. varus.

Congenital deformity of the spine is rare; its treatment

CONGENITAL MALFORMATIONS.

may be deferred to the lecture on Spinal Curvature. [The
figs. 136 to 144 represent the malformations which oftenest
present themselves in medical practice. When susceptible
of relief, they require to be treated according to common
principles. The author has usually overcome shortening
of parts in these cases by mechanical extension, having
been unwilling in the treatment of malformations, at the
best capable only of slight amelioration, to employ teno¬
tomy with the risk of discrediting it.

Fig. 144.

Posterior view of the same malformation, p, plantar surface of toes; s, part corresponding
to the sole; h, the heel; a, tendo Achillis. The subject, set. about 14, walked
tolerably, well. He concealed the malformation, by inversion or rotation inwards of
the entire limb, and by wearing a suitable boot.

The next instance of congenital distortion and mal¬
formation is sufficiently interesting to merit publication
in these Lectures. It was that of a male child, and is
thus recorded in the author’s journal: “The father is
a person of literary and sedentary habits, the mother a
person of delicate frame, subject to dyspepsia, hepatic
derangement, hemorrhoids, attacks of constipation lasting
from ten to twenty days—the bowels in fact rarely acting
except at intervals of several days; she has borne one

334

CONGENITAL MALFORMATIONS.

other child, at present aged about three years, delicate,
and liable to * fits’ during dentition. Whilst pregnant with

Fig. 145.

Congenital distortion and malformation. Left limb almost entirely severed in utero,
probably from constriction by umbilical cord.

the subject of these remarks, she suffered greatly from the
movements of the foetus, and from pain in the right iliac
fossa. During three months preceding parturition, which
occurred at the eighth month of gestation, she was confined
to her apartment, and became helplessly weak. The labour
itself was not difficult; but at the birth the accoucheur
observed that the limbs were encircled by the umbilical
cord in an extraordinary manner.

“The child is two months old, well nourished and
lively; the head is less firmly supported by the cervical
muscles than usual at this age, and sinks towards the left

CONGENITAL MALFORMATIONS.

shoulder. On the left side of the neck a deep groove is
perceptible, the transverse processes on right side of neck
being particularly prominent. It appears probable that
during uterine existence the head has been constantly in
close apposition with the left shoulder. The trunk ap¬
pears disproportionately large, even in relation to the usual
predominance of this partin infancy*—probably the re¬
sult of the intra-uterine arrested development of the lower
extremities, and their deficient growth subsequently to
birth. The four extremities are malformed, each of the
upper extremities being similarly affected, whilst in the
lower limbs the deformity appears to differ on each side.
Examined in detail, the arms are observed to be inwardly
rotated to the utmost extent, the shoulders prominent from
deficient development of deltoids; superior articulations of
the humeri movable, but the limbs can be carried upwards
and outwardly to a less extent than in other directions.
The olecranon processes present outwardly and somewhat
anteriorly; very slight mobility at elbow-joints exists,; in
consequence of the inward rotation of humeri, the fore¬
arms are moved during flexipn towards the dorsal rather
than towards the anterior aspect of the body, as in the na¬
tural formation of these organs. The wrists are pronated
and flexed ; the palms presented outwardly, in consequence
of the inward rotation of the humeri; whilst the inner
margins of the hands are approximated to the ulnas. The
thumbs and fingers are contracted towards the palmar sur¬
faces, but little mobility of wrists and fingers remains.
The humeral portions, especially towards the shoulders, ap¬
pear less fleshy, and the right hand is more atrophic than
the left. A slight groove, concave from above downwards,
extends across the dorsal surface of left metacarpus;
whilst a continuous groove, extending in a spiral manner
about two turns and a half around the lower portion of
forearm and carpus, gives to this hand and arm a singular
* The drawing is in this respect inaccurate.

336

CONGENITAL MALFORMATIONS.

shape. This groove, in a part of its course, namely, on
the proper anterior surface of the extremity of the fore¬
arm, increases to a deep cleft, the integument at bottom of
this cleft being abnormally adherent to the subjacent bones.

“ The thighs are rotated outwardly ; the patellae conse¬
quently, of which the left is more rudimentary than the
right, present externally; their situation is marked by a
deeply wrinkled depression in the integuments, to which
they appear to adhere. The knees are somewhat con¬
tracted, the obstacle to their extension being firm, the left
more unyielding than the right. The feet have the form
of Talipes varus, the right assuming the intermediate, and
the left the most complete grade of that affection. A
crease, deeper on the internal than on the external aspect,
extends spirally around the middle of the right thigh;
whilst four spiral turns of a deep cleft exist in the left
limb, two above and two below the knee-joint. About
the middle portions of the left thigh and leg respectively,
two spiral turns (b and c ) constitute fissures so deep that
the cutis is here in close proximity to the bones ; the inter¬
mediate portion of the member ( d ) being connected with
upper portion of the thigh and the lower portion of the
leg, by the attenuated thigh and leg bones, invested in
these situations by very fine integument only. In fact,
where the two principal clefts occur, the distal portions of
the member are maintained in connexion with the proximal
portions by merely the shafts of the bones, the nerves and
blood-vessels, and thin laminae of cutaneous tissues. The
parts of the member placed between the two principal
grooves are, on the contrary, bulky—preternaturally de¬
veloped.”

Such were the deformities in this unfortunate infant,
whose functions of organic life were naturally performed.
The author’s opinion being requested respecting the prac¬
ticability and propriety of adopting remedial means, he was
induced to state his belief that, whilst the lower extremities

CONGENITAL MALFORMATIONS.

might be sufficiently restored for the purposes of imper¬
fect locomotion, and the upper extremities improved to
the extent of enabling the infant to approximate the hands
to the mouth, yet that very slight general function of the
hands and arms would be obtained. Section of Achilles
tendon in both feet, that of tibialis posticus in left foot,
application of splints, with manipulations to the ankles,
knees, and wrists, and a spring instrument applied for
gradual flexion of the elbows and inward rotation of hu¬
meri, sufficed, within six months, to effect first part of
treatment, namely, the restoration of nearly complete form
and flexibility. Three months later, the child had acquired
some power; he was enabled to shrug the shoulders, in¬
wardly rotate the arms, and grasp toys with the hands,
but had obtained no capability of voluntarily acting upon
the deltoids and raising the arms; the voluntary move¬
ment of the elbows was exceedingly limited.

The form and flexibility of the feet were fairly re¬
stored ; the processes of the left tibio-tarsal articulation re¬
mained sparely developed ; the knees were much straighter,
and more movable; the outward rotation of the thighs
much less constant; the child could playfully throw these
limbs about, adduct them, partially bend the knees, and
gave promise of realisation of the expectations entertained
of their restoration to a certain degree of usefulness.

At eighteen months, however, having occasionally suf¬
fered whilst cutting teeth, he was carried off somewhat
suddenly by convulsions.

Death having occurred at the distance of 200 miles
from London, no opportunity of post-mortem investigation
was offered.

The links in the chain of pathogenetical causes were
probably as follow: Impaired constitutional power in the
parent having predisposed to derangement in the cerebro¬
spinal system of the embryo—intra-uterine convulsions of
the foetus—atony and paralysis of certain muscles, with

338

CONGENITAL MALFORMATIONS.

inordinate action and shortening of other muscles, as con¬
sequences of such cerebro-spinal derangement—entangle¬
ment of limbs by funis (itself the accidental result of the
convulsions, but the cause of the uncommon spiral grooves,
fissures, and clefts).]*

I have entered slightly into the consideration of the
causes of these malformations; enough has been said to
suggest to you materials for thinking. Some of you may
avail yourselves of the hints given, and be enabled, by
further research, to clear away the difficulties that sur¬
round the comprehension of intra-uterine abnormal acts.
It was remarked to me by Stromeyer in 1835, that in his
opinion every congenital change of form (whether true mal¬
formation or distortion) would some day be traced to ab¬
normal muscular action. This opinion may be too exclu¬
sive ; hut I believe I have been able to confirm, in many
respects, the dictum of this able pathologist and prac¬
titioner.

* Dissertatio de Acephalis, Elbin: Berolini, 1821.

339

LECTURE XVII.

On deformities of the spinal column—Angular curvature from scrofulous
disease of the column and from injury—[Lateral deformity from
struma, rheumatism, injury—Disease of vertebra mistaken for pul¬
monary consumption, for hip-joint disease—Mode of production of
paraplegia—Terminations of strumous disease of vertebra]—Angular
curvature from rachitis —[ Antero-posterior curvature — Incurvation ]
— Treatment—Complication of neuralgia and spastic-contraction
of muscles of the limbs — Congenital spinal deformity.

In this lecture I propose to describe the principal forms of
spinal deformity, and to compare them with the distortions
affecting other parts of the frame. The observations I have
to make will be compressed into the smallest practicable
space. Much has been written on the subject of spinal
distortions, yet it is probable that the members of the
profession are less agreed respecting their nature, or at all
events less satisfied with the mode of treating these com¬
plaints, than with the knowledge possessed of any other
branch of pathology. For my part, I may confess, that at
a period when the pathology of other distortions had ceased
to be a source of embarrassment, that of spinal curvatures
appeared to be involved in so much obscurity that I be¬
came convinced of the necessity of commencing a funda¬
mental inquiry into the subject. I shall endeavour simply
to relate the principal pathological phenomena on which a
proper comprehension of those distortions, in my opinion,
depends.

The nature and treatment of spinal distortions has ap¬
peared obscure, because they have been long treated as a
speciality, instead of being investigated in connexion with
universal pathology (1843). I do not mean to -assert that
they have not been properly studied by numerous prac¬
titioners here and elsewhere, but that by the majority of

340

DEFORMITIES OF SPINAL COLUMN.

writers on spinal distortions they have been regarded in
too narrow a point of view. Disease affecting the various
structures composing the vertebral column has too often
been supposed to follow a course peculiar to this region;
whereas observation shews that a certain kind of disease
being given, it may properly be inferred that its effects in
this region will correspond with its effects elsewhere. If the
vertebral column be examined, it is found to be composed
of bones, ligaments, intervertebral bodies, muscles which
regulate the position of the whole, and a nervous cord con¬
tained within the column. The last may, for the present,
be excluded from our consideration, as any lesion of its tex¬
ture is entirely secondary. Of the remaining structures the
intervertebral bodies may he dismissed, as it is universally
admitted that in the ordinary forms of spinal deformity they
are also secondarily affected. We have, then, to consider
the diseases of the bones, ligaments, and muscles of the
vertebral column, and the resulting deformities. It may be
asked, Is there any known difference in the composition of
the bones, ligaments, and muscles of the spine, that any
difference in the effect of disease in this region compared
with its effects upon the bones, ligaments, and muscles of
any articulation of the upper or lower extremities should
be anticipated ? We know of none. The effects of disease
in this situation may be modified by the peculiar func¬
tions of the spinal column, its office being to support the
head and trunk in its erect posture, and to serve as a
point d'appui for the action of the muscles of the extremi¬
ties. The spinal column is, from the nature of its office,
exposed to disadvantages from which the members are
more free. If, for instance, an individual have strumous
disease of an articulation of the lower extremity, the use
of the articulation may be entirely discontinued, either in¬
stinctively or as the result of proper advice. The effects
of the disease are confined to the loss of the use of the ar¬
ticulation and a certain constitutional disturbance. But if
the same disease should attack one or more of the articu-

ANGULAR DISTORTION.

341

lations of the spinal column, the office of this part is such,
that during every movement of the frame, and during the
principal movements of the members, the diseased part of
the spine is exposed to vibration and motion, from which
the articulation of a limb is exempt. In the extremity the
weight of the body is not necessarily borne on the affected
part; it may, at the commencement of the disease, be easily
withdrawn from it by repose of the member. In order to
give the spine repose, we are compelled to rest the entire
frame. In the spine the difficulty of diagnosis often pre¬
vents recognition of disease in its earliest stages; it often
proceeds unnoticed until indicated by deformity (p. 346).

After these few general observations, you are ready to
infer, that as disease may affect the articulations of the ex¬
tremities, similar results may occur in those of the vertebral
column. Struma, accidents, and rachitis are common causes
of deformity in the extremities, and it will excite no surprise
to hear that these causes may equally affect the component
parts of the vertebral column. The muscles of the spinal
column are in structure identical with those of the extre¬
mities ; and wherefore should they not participate in para¬
lysis and spasm, and undergo atrophy, organic shortening,
and elongation, abnormal conditions which, as we have seen,
are so common in the different members ? As, in a limb,
improper positions may induce deformity, should we not
expect that vicious attitudes should occasion spinal distor¬
tion? and, lastly, as congenital deformities occur in the
limbs, ought we not to anticipate their occurrence in the
vertebral column ? In short, then, you are prepared to
understand that the pathology of deformities of the spine
perfectly corresponds with that of the members. The time
at my disposal will preclude allusion to every variety and
symptom of spinal deformity. I shall principally con¬
fine myself to analogies, and describe the characters and
treatment of the most common distortions of this part.

342

DEFORMITIES OF THE SPINE.

Strumous Disease and Deformity of Spinal Column.

A common disease of the extremities of the long hones,
the condyles of the femur for example, in which the cancel¬
lous structure so largely predominates, is the transformation
of this structure into a material of less density and strength,
apparently from removal of calcareous particles, and deposit
of tuberculous matter in their place. The ligamentous
structures equally suffer in many cases. You know further,
that considerable deformity of the knee may result without
occurrence of external suppuration; that is to say, with¬
out formation of what is technically denominated abscess;
whilst, in other cases, the product of inflammation of the
joint, and of the disorganisation of the bones and ligaments,
is discharged externally. The same processes occur in the
spinal column, the bodies of which equally abound in can-
celli. "When the individual walks with an articulation of the
lower extremity thus affected, the part yields to the super¬
incumbent weight; or, whether the use of the part be dis¬
continued or not, the stronger mass of the muscles displaces
the articular surfaces, flexes the articulation, and in time,
these muscles becoming structurally shorter, permanently
contract the articulation. In the same manner, when the
structure of the bodies of the vertebrae and the ligaments
become disorganised by strumous disease, the part either
yields beneath the superincumbent weight of the head and
upper portion of the trunk, or curvature forwards of the
thorax ensues, through the action of the abdominal mus¬
cles. These, by the advantage of their mechanical arrange¬
ment, possess a greater power of bending the spine ante¬
riorly than the large muscles of the spine have to draw it
backwards beyond the perpendicular line.* The arrange-

* General writers on morbid anatomy, and special authors on distortions,
abound in materials illustrative of the morbid anatomy of disease of the spine,
and the mechanism of the production of curves and supplemental curves
whenever the equilibrium of the column is disturbed.

ANGULAR AND LATERAL STRUMOUS DEFORMITY. 343

ment of the transverse and spinous processes prevents a
backward falling (incurvation) of the upper part of the trunk,
especially as the body of the vertebra is the principal seat
of the affection. The distortion seldom occurs in these cases
laterally. It is sometimes both forwards and lateral.* The
falling of the thorax taking place ante¬
riorly, the spinous processes of the de¬
cayed or carious vertebrae project pos¬
teriorly, hence angular curvature re¬
sults ( cyphosis , gibbus ). In this series of
models of angular curvature from this
cause, you may observe the great ex¬
tent of deformity, and consequently
how large anumber of vertebrae has par¬
ticipated in disease. This model (fig.

146) will shew you the ordinary situa¬
tion of the curvature ; it involves, in
this instance, the whole of the dorsal
vertebras. You are rendered familiar
with scrofulous disease of the ver¬
tebrae in the mode in which it affects

* The author refers the reader who may be desirous of studying in. detail
the different forms of disease of spinal column to the writings of standard
authors on general surgery, amongst whom Stromeyer stands pre-eminent for
his treatment of this subject (j Handbuch der Chirurgie von Dr. Louis Stro¬
meyer, Freiburg im Breisgau, 1846 ; vol. i. part iii. Principles and Practice
of Surgery of Ferguson, Pirrie, and Miller). Stromeyer has explained the
occurrence of lateral yielding of the column, and the rotation.which occurs
in some instances from strumous synovitis. He thinks it arises from tume¬
faction of the ligaments of an articulation of the oblique processes and aug¬
mentation of synovia in this joint. “ A lateral curve of more angular character,
limited to a small number of vertebrae, occurs, which is usually compensated
for by other gentle lateral serpentine curves of the column. By this means
the equilibrium is restored, and the deformity remains unperceived through
the dress” (p. 545). A case of extreme lateral displacement of vertebrae from
strumous or rheumatic disease, which had been mistaken for cancerous or
other tumour, was recently described to me by Mr. W. Adams.

f The illustrations of spinal deformity by Bampfield, Shaw, Harrison,
Lafond, Delpech, Humbert, Pravas, and many others, who wrote before the

Fig. 146.

Extreme Angular spinal curva¬
ture from disease and caries
of vertebral (ankylosis), t

344

DISTORTIONS OF THE SFINE.

tlie lumbar vertebras, by the frequent production of lumbar
or psoas abscess. The cervical vertebras also are often the
seat of the affection, the resulting deformity being either
angular or lateral. When the latter exists, the position of
the head resembles that in wry-neck. You will be daily
informed that the spinal disease has resulted from injury.
As in strumous diseases in other situations, so in the spine,
an injury to the part may have provoked the development
of disease; but whether clearly preceded by injury or not,
the progress of disease and deformity is uniform. Angular
curvature may result from premature over-exertion in a
stooping position, in a susceptible constitution.

[The chest undergoes considerable
change of form in angular spinal defor¬
mity, the inferior ribs appearing much
compressed laterally, and the sternum,
as at fig. 147, very prominent, especially
at its inferior extremity.]

Distortion of front of chest T . .

■consequent upon angu- In practice, cases ox this spinal de-
tar spinal deformity. f orm ity -will be presented to you in which
disease still exists, whereas in others you will have solely
to give an opinion concerning the remediableness of defor¬
mities in which false or true ankylosis may be present. So
long as you recognise the existence of diseased action, the
object you will have in view will be to diminish the local
disturbance by counter-irritation, and sometimes by leeches;
to improve the state of the constitution by proper diet and
air, administration of steel, iodine (ol. morrhuas), with oc¬
casional laxatives, and endeavour to prevent deformity by
suitable position. Ankylosis and deformity are said to be

publication of these Lectures, enable the author to dispense with illustrations
of every stage of spinal angular deformity. The author has adopted a contrary
course with the illustration of many distortions of the members, not only
with the view of facilitating comprehension of the subject, but because
some of those distortions were first brought to the notice of the profession
and described by himself..

Fig. 147.

ANGULAR DEFORMITY.

345

necessary for the recovery of persons thus affected. No
doubt can be entertained that when the bodies of nume¬
rous vertebrae are destroyed by caries or interstitial ab¬
sorption, the falling in of the vertebrae and consolida¬
tion of their remains is essential to recovery from the
primary effects of disease. It is equally certain that the
perpendicular position of the trunk, and consequent pres¬
sure of the vertebras upon each other, is one of the cir¬
cumstances which not only aggravates the disease in its
several stages, but tends to increase the destruction of the
bodies of the vertebrae. The recumbent posture is, in
these cases, universally acknowledged to be essential.
Some practitioners recommend the prone position, and in
many instances this is preferable. You will decide on re¬
pose, either on the chest or back, according to the cir¬
cumstances of the case. When, for example, the lumbar
vertebrae are diseased, the prone position leaves the bodies
of these vertebrae less exposed to pressure than when in
an intended horizontal position on the back in a common
bed; the head and shoulders being raised by pillows, a
bent position is attained, which favours lumbar, dorsal, or
cervical posterior protrusion.

When, on the subsidence of local diseased action and
consequent constitutional, disturbance, you are consulted
concerning the angular deformity dependent upon destruc¬
tion of bodies of one or more vertebrae, it is necessary
to determine, 1st, whether any means for straightening a
spine under such circumstances can be resorted to; or 2d,
whether any means can be applied to prevent increase of
deformity. The first is impossible; or, if possible, the
straightening would not be permanent. The second is
practicable. If you reflect on the tendency to increase of
deformity evinced in every part of the frame when the
superincumbent weight is improperly received and trans¬
mitted, you will suppose that on the occurrence of a spinal
curvature from scrofulous disease or from injury, the proper

346

DISTORTIONS OF THE SPINE.

relation of the parts of the column being destroyed, the
weight of the head and shoulders will operate disadvan¬
tageous^, and tend to increase the deformity. Such is the
fact. We daily observe, in young people, even after the
cessation of vertebral disease, that unless the spine be sup¬
ported, the angular curvature, confined at first to a few
vertebrae, extends to the greater part of the column. It is
therefore essential to continue recumbency long after the
subsidence of strumous spinal disease; and if exercise be
permissible before adult age is attained and the growth of
the frame perfected, proper mechanical support to the spine
is needed. Use the opportunities of watching the effects
of this disease in private practice as well as in this institu¬
tion, and the accuracy of the remarks made on the neces¬
sity of mechanical support in these cases will be confirmed.
Many prejudices exist against mechanical support; these
have arisen less from any injurious influence really exer¬
cised, even by inappropriate apparatus, than from the fre¬
quent inefficiency, even of the best-constructed piece of
mechanism, to arrest the tendency to increase of deformity.
For apparatus see Lateral Curvature, p. 356 and p. 375.

[The progress of strumous disease of vertebrae is often
destructively insidious, and sometimes simulates other dis¬
eases. Thus the author has repeatedly been consulted for
the resulting deformity of the dorsal region in adolescent
cases, which in the early stage had, on account of the atten¬
dant failure of general health, with cough and hectic symp¬
toms, been attributed to phthisis. It is not surprising that
so serious a disease as tuberculous degeneration of upper
and front part of the thoracic vertebrae, with tuberculous
suppuration in that locality (not necessarily proceeding out¬
wardly), should disturb the bronchial glands (these being
sometimes conjointly affected), and the roots and apices of
the lungs, and closely simulate phthisis. Disease of dorsal
vertebrae often proceeds to considerable extent without
detection, through inattention to “ ocular investigation of

DIFFICULTY OF DIAGNOSIS.

347

the chest.” Sometimes the occurrence of dorsal deformity
is fearfully rapid, not even discovered until a sudden attack
of paraplegia has exposed the true nature of the illness
under which the patient has laboured. The author has
witnessed one case in which the bodies of several dorsal
vertebrae had been excavated by chronic strumous disease,
the undermining process having proceeded until, the spinal
column suddenly, in a single night (as was reported), gave
way. Possibly, in some similar cases, the first visible traces
of deformity having been simply overlooked, the sudden
paraplegia has resulted from the tolerance of compression
by the spinal cord having reached its maximum; precisely
as a certain amount of physical cause of apoplexy or pa¬
ralysis within the cranium may be tolerated without warn¬
ing, whilst the smallest addition to the existing lesion suf¬
fices to excite the whole of the symptoms.* Many cases
of angular deformity (perhaps the majority) take place with¬
out pain. Some patients complain of pain along the course
of the intercostal nerves, or in the upper or lower extremi¬
ties. Pain is rarely referred to the affected spot, sometimes
only upon voluntary motion, or when the trunk is improperly
moved by the attendants.f Strumous disease of the lum¬
bar vertebrae sometimes simulates hip-joint disease. The
disease being situated on the anterior portion of the column,
involves neighbouring structures; whether or no any pus be
formed and point outwardly, the psoas muscles, usually on
one side only, are, from juxtaposition and mechanically,

* Paralysis is not in proportion to deformity; it may either precede de¬
formity or even independently occur, not always through mechanical compres¬
sion, but from disease of vertebrae extending to the cord or its membranes.
Paralysis of upper extremities may occur from struma affecting cervical ver¬
tebrae.

+ The only safe mode of moving or carrying severe cases is upon a sheet
or litter, in the horizontal posture, by which means the weight of the head,
trunk, and limbs being equally distributed upon the supporting surface, the
spine is protected from any strain. On the contrary, the act of lifting the
child by the head and shoulders and pelvis, in the ordinary manner, tends to
bend the spine at the weakest part.

348

DISTORTIONS OP THE SPINE.

interfered with, the voluntary movement of the hip suf¬
fers, claudication and atrophy ensue, and sometimes disease
of hip is incorrectly diagnosed (see note, p. 66). These
errors of diagnosis are sometimes excusable, as the consti¬
tutional symptoms of strumous disease in the lungs, ver¬
tebrae, or hip are the same. The total oversight of the
disease is not remarkable when its course is very chronic,
and the constitutional reaction is so feeble as not to en¬
gage attention.

The most favourable termination of strumous disease
with deformity of cervical, dorsal, or lumbar portion of
the spinal column, is that in which the disease proceeds in
a chronic form—involves a limited number of vertebrae
only, and the resulting accumulation of pus or softened
tuberculous matter is not discharged outwardly or into
neighbouring internal organs, but is absorbed, leaving only
the putty-like or calcareous deposits found many years
afterwards attached to the front of, or in the vicinity of,
the decayed bodies of the vertebrae. Sometimes the pus
travels outwardly, constituting the too well-known psoas
and lumbar abscesses. In some instances, probably, the
matter takes the course of the root of the lungs, the bron¬
chial glands, and the trachea; although this is a compara¬
tively rare termination. It may be discharged into the
descending colon, and escape per anum.* Profuse suppu¬
ration may continue for weeks through this channel, with
simultaneous evacuation of masses of coagulated lymph;
the so-called “sloughy cellular membrane” discharged from
abscesses in the limbs much resembling the material dis¬
charged in diarrhoea tubularisf (croupal). The author in

* See Pirrie, Principles and Practice of Surgery, p.442: London, 1852.

•}• Hippocrates (Sydenham Soc. Transl. vol. ii. p. 603), speaking of disease
of vertebra, states, “ some have been carried off by a dysentery when it be¬
comes chronic.” Dr. Adams, the learned translator, expresses difficulty in
comprehending this assertion of Hippocrates, and states, “those cases in which
the disease is said to be carried off by dysentery, were no doubt of a rheu-

MODES OF TERMINATION AND SECONDARY EVILS. 349

one case thought he witnessed the discharge of a consider¬
able length of gangrenous intestine.

It is unnecessary to do more than allude to some of the
secondary evils of all spinal deformities, which diminish the
capacity of the thorax and abdomen, and proportionately
embarrass the functions of the contained organs (see p. 18).
Chronic derangement of any or all of these parts is apt to
be maintained; and the occurrence of any acute disorder
within either of these cavities places the sufferer in dispro¬
portionate jeopardy, and frequently requires the most active
treatment for its relief. This is especially the case when
pneumonia, pleurisy, bronchitis, or broncho-pneumonia are
produced. Thus venesection, a remedy so little employed
in the present day, may in these subjects be urgently
necessary as a mechanical mode of relieving the impeded
organs. Or if the case be not sufficiently alarming to
warrant any “ heroic” remedies, the knowledge of the ex¬
tent to which severe spinal distortion may aggravate in¬
ternal disease will cause the attendant to be more than
usually solicitous and vigilant during the earlier stages of
inflammatory disease. These observations apply less forcibly
to those affected with deformity who are persistent invalids
than to those who are comparatively strong and able to de¬
vote themselves to the active duties of life, in whom, there¬
fore, the stages of acute disease will proceed at a more
rapid rate (p. 856).]

matic nature, and not connected with organic disease of the vertebrae. ” The
author’s observation of the terminations of disease of the spine leads him
to confirm the accuracy of the idea of Hippocrates, in so far as concerns the
existence of a connexion between the dysentery and organic disease of the
spine. By dysentery, Hippocrates here probably meant discharge of pus per
anum, with, as he terms it, “ blood and scrapings of the bowels or Hip¬
pocrates may have alluded to another fatal mode of termination of caries and
deformity of spine, namely, that of diarrhoea, caused by tuberculous, folli¬
cular, and mesenteric disease, or by aphthous inflammation of the tube, with
hectic.

350

DISTORTIONS OF SPINE.

Rachitic Curvature of Spine,

Angular [and posterior]* deformity often arises from that
peculiar change in the bones, ligaments, and other fibrous
structures denominated rachitis.]* When the proper firm¬
ness of the parts of the vertebral column is so completely
destroyed that its maintenance in the straight position is im¬
possible, the thorax inclines forwardly, and an angular [or
posterior] curvature, [excurvation] results. The curve, from
this cause, is, as represented in this model (fig. 148), more
uniform than from scrofulous disease [usually less angular,
in fact]. Often one spot in particular cannot be accused as
the seat of the curvature; the case resembles, in the com¬
mencement, the curve which may voluntarily, during health,
be given to the column. When it exceeds this, a more de¬
cided angle is observed from the projection of one or more
of the spinous processes. Ultimately the angular deformity
may equal that from caries of the vertebrae, as at fig. 146.
Corresponding concavities occupy the cervical and lumbar
regions. Difficulty may occasionally be experienced in de¬
termining, from examination of the resulting deformity,
whether the origin of an angular curvature has been scro¬
fulous or rachitic. In the commencement no uncertainty
can exist, the difference in the constitutional symptoms of
struma and rickets being well marked.]; The complication of

* The distinction between angular and posterior curvatures is unneces¬
sary. Originally the term ‘ angular’ was restricted to deformity from caries
(struma); but deformity from this cause is not angular until it attains an
advanced stage, and rachitic posterior curvature may become angular in its
progress. .

f Rachitic cyphosis or rachitic gibbosity, as distinguished from the similar
deformities from strumous caries (ankylosis) (p. 343).

X Portal and the earlier writers on spinal deformity have confounded caries
of vertebrae, rachitis of the column, and ordinary “lateral curvature,” under
the one head of rachitis (j>&x LS > the spine). Rachitis, a general affection of
the osseous system, was formerly supposed to be peculiarly connected with
disease of the spine; whilst modern observation, guided by morbid anatomy,
shews that scrofulous disease of the vertebrae ending in disintegration (caries)

RACHITIC DEFORMITY OF SPINE.

351

other forms of strumous or rachitic disease with the spinal
curvature will clear up all doubts, even at a late period, in
the case. When local tumefaction and pain augmented on
pressure exist, you will recognise the scrofulous disease.
Rachitis produces its effects without local reaction [some¬
times even without very evident general disturbance of
healthbeyondweakness]. This rachitic deformity is identical
in its effects upon the form of the column with the state often
considered as mere debility. Infants may be brought to
you presenting the first stage of angular spinal deformity,
from having too early been excited to assume the erect
posture, or from rachitism. Whether rachitic angular [or
posterior] curvature occur in infancy or childhood, abso¬
lute recumbency is indispensable, until you perceive, by the
indications of returning general health and strength, that
the rachitic state of system has subsided. After the re¬
marks in. former Lectures on the general treatment of
rachitis, it is unnecessary here to advert to it. Rachitic
curvature may partake of the lateral as well as of the
angular character.

The treatment of scrofulous and rachitic disease and
deformity of the spinal column consists, for the most part,
of alleviation of symptoms during their progress, improve¬
ment of constitutional powers, and prevention of defor¬
mity. We possess no royal means of restoring the proper
firmness of the osseous and ligamentous fabrics. In rachitic

is more destructive than well-marked rachitic affection. It will be seen in the
next lecture that the author is of opinion that ordinary lateral curvature results
from impaired nutrition of the muscular and osseous systems, and conse¬
quent debility of the vertebral column, and is therefore allied to rachitis.
The circumstances which led the older writers to connect rickets with the
spine, and a fortiori with the nervous system, were probably the frequent
co-existence of rickets with hydrocephalic and hydrorachitic affections—the
occurrence of nervous lesions in rachitis, incontinence of nrine for example—the
remarkable hollow of the loins (lordosis, \opS6a, to bend forwards), and re¬
tarded power of walking in rachitic children, incorrectly attributed to the
weakness of paralysis. See Lectures on Paralytic and Rachitic Lameness.

352

DISTORTIONS OF THE SPINE.

deformity, you may with less hesitation recommend me¬
chanical supports, as unquestionably greater benefit accrues
from their use in these cases. After
several years’ duration even of rachitic
deformity, the change of form induces
other extensive changes of structure.
Preparations in anatomical museums
testify that, although changes of form
occur without destruction of parts, yet
in the progress of growth the develop¬
ment of some parts is impeded, and of
others facilitated; so that in long-stand¬
ing cases of spinal deformity from rickets,
you may observe the vertebral bodies
compressed, and altered in their indi-
Rachitic angular or pos- v idual forms to accommodate them to

terior curvature of spine.

the altered relation of parts. This will
explain the impossibility of [completely] rectifying the
position of the column after several years’ duration of
deformity during adolescence (see note, p. 381).

[A common deformity of spine arises from the age of six
to sixteen, especially amongst rapidly growing schoolboys,
consisting of slight posterior curvature (convexity back¬
wards, excurvation) of upper dorsal region (“ round-shoul¬
ders”), and incurvation, lordosis (concavity backwards), in the
lumbar region. The remote cause is undoubtedly, in many
cases, a slight constitutional taint of rachitis, proved by the
child having whilst an infant suffered from genu valgum
(p. 209) (perhaps very slight), or from rachitic valgus, or
pigeon-breastedness (p. 214). The exciting cause is the
undue proportion of time devoted to sedentary pursuits,
especially to the excessive writing which characterises the
system of education pursued at some public and private
schools. In many instances, the hours spent in writing
are uncompensated for by use of ample play-grounds, and
encouragement to the rude amusements necessary for the

IMPEDIMENTS TO CURE.

proper development of tlie boyish, frame. Where no ra¬
chitic element is discoverable, debility from over-growth
may have been the remote cause.

In the early stage this antero-posterior yielding of the
vertebras disappears when the subject is recumbent; but
in the advanced stage the muscles situated in the concavi¬
ties of the curves, as well as the articular surfaces, having
adapted themselves to the altered relation of the parts, the
change from the perpendicular to the recumbent posture
effects no variation in the deformity of the dorsal region,
and seldom in the lumbar region, unless the thighs be
flexed; by which means the psoas muscles being relaxed,
the lumbar vertebrae sink towards the couch. Even this
temporary alleviation of the deformity, with the lapse of
time, disappears. This distortion may be accompanied
with nocturnal inability to retain the urine ; and by alter¬
ing the angle of the upper outlet of the pelvis, may occa¬
sion in females, who at a later period become pregnant,
difficulty in parturition. The injurious effect upon the
thorax is less considerable than that resulting from other
spinal deformities. The treatment of this antero-posterior
vertebral curvature consists in obviating the constitutional
rachitic state, when still present; in removal of the exciting
causes enumerated; and by a judicious system of mode¬
rate gymnastic exercises and youthful strengthening games.
If the lumbar hollow be very considerable in an adoles¬
cent, the distortion is never completely remedied.]

In discussing the practicability of straightening a spinal
column that has long remained distorted from any of the
causes which affect this region, it is necessary to take into
consideration not only the nature of the primary lesion,
but also the secondary phenomena resulting from the con¬
tinuance of the column in an improper position. I have
already mentioned a fact, which you may verify by exa¬
mination of pathological specimens, namely, that the bodies
A A

354 ANG. AND POST. DEFORMITIES OF THE SPINE.

of the vertebras, through curvature in any direction, are,
during the period when the growth of the frame is in pro¬
gress, retarded in their development on the side to which
the spine inclines, whilst they may attain the normal pro¬
portion, or exceed it, on the convex side (see note p. 381).
It follows from this circumstance that although after restora¬
tion in childhood and early adolescence, we may expect the
parts of the column again to return to normal proportions,
or to approach these, yet that after completion of growth,
even if restoration of the perpendicular direction be pos¬
sible, we cannot expect the pillar to maintain the position,
unless, at all events, we should posses^ the means of sup¬
porting the spine for many years in a proper form by
mechanical apparatus. Another secondary phenomenon
results from the adaptation of the numerous ligaments of
the column to the altered relation of parts. They be¬
come respectively contracted and elongated, and constitute
a considerable obstacle to rectification. This obstacle will
appear to you the more considerable when you reflect that
the ligaments connecting each vertebra are naturally very
short; and the shorter the dense unyielding substance to
be stretched, the greater the difficulty of attaining this end.
Again, the innumerable short muscles which occupy the
spaces between the different processes of the vertebra;
possess, for a similar reason, an equal power of obstruct¬
ing restoration. When, in addition, you remember that
the ribs may have become adapted to their altered rela¬
tions, and have become changed in form and even adherent
to each other, you will understand to what extent the new
arrangement of these bones may impede recovery at a cer¬
tain age.

These are considerations which, notwithstanding the
conviction that the pathology of spinal deformities is that
of the rest of the frame, and that similar principles should
be applied to the cure of the same diseases wherever
situated, guard the rational practitioner from disappoint-

VALUE OF MECHANICAL SUPPORTS.

355

ment. Deformities in. the extremities, from incomplete
ankylosis , or from rachitis, may be susceptible of restora¬
tion, owing to the facility and power with which mecha¬
nical means may he brought to bear in these situations;
but in the spine mechanical appliances cannot be so advan¬
tageously and effectually applied. Hence the inutility,
with reference to cure , of the numerous extension-beds,
most ingeniously contrived for elongation of the spinal co¬
lumn. They may afford some relief in certain conditions;
they may serve to remove pressure from nervous cords
under certain circumstances; but this is the limit of their
applicability. Much charlatanerie has been practised with
couches of various kinds : every addition to a common
couch, which subserves the comfort of the patient, which
enables the individual better to minister to his amusement
or occupation, is commendable; but every such couch, the
claims of which as a “ curative” method are advocated, is
not entitled to your confidence.

I have already insisted upon the advantages derivable
from support to spinal columns in strumous and rachitic
curvatures particularly during the growing period of life.
You should not conclude that this is the only period during
which they may be required. Often at adult age, with
recovery of robust health, no necessity for mechanical sup¬
port may exist. You may constantly meet with persons
thus deformed who perform most of the offices of life in
comfort, unassisted by instruments; but if the individual
be of a weakly constitution—a delicate female, for in¬
stance— the utmost relief is obtainable from proper sup¬
port. Many individuals in this situation, to whom life
appears a burden, will be so greatly benefited by removing
the strain which is in these cases maintained upon the
curved part of the spine, that they will acquire health
and activity to which they may have long been strangers.
It is unnecessary to describe all the forms of apparatus
available in these cases. The principle upon which the

356

DEFORMITIES OF THE SPINE.

majority of these instruments is constructed is that of
making the pelvis available as a fixed point from which
metallic supports extend to the axillae, or to the project¬
ing ribs and angle of the spine. Splints formed of leather
[or gutta percha] sometimes afford an efficient support to
the trunk in the upright position (see p. 374).

Among'the secondary evils of severe angular curvature
[or posterior] from either of the causes enumerated, are
neuralgic pains in the trunk and extremities, from pres¬
sure on the sensitive nerves as they emerge from the
spinal canal; and a contracted state of all the articulations
of the lower extremities, resulting from similar injury to
the motor fila'ments. A smaller amount of pressure will
suffice to produce neuralgia than spastic contraction of
muscles; indeed the latter, when severe, appears to result
from pressure (?) on the entire cord, and is usually accom¬
panied with neuralgia. These serious complications may
occasion excruciating suffering, and are difficult of alle¬
viation unless the spine can, by the means already enu¬
merated, he in part restored to a proper form. As a
palliative to pain, narcotic applications externally, warm
embrocations of laudanum, plasters of belladonna, and
aconite, or the preparations of veratria may be employed.
If the general health be perfect, the contracted state of
the limbs have long been stationary and unattended with
pain, you may infer that the contraction is less the result
of actual pressure on the nerves than of organic shortening
of muscles, from long continuance of the parts in a con¬
tracted position after subsidence of the contracting cause.
Here the question of tenotomy may be entertained. I
have occasionally had recourse to it with advantage; but
I recommend previous perseverance in the use of frictions,
manipulations, and mechanical extension.

The antero-posterior and the transverse diameter of the
thorax are often enlarged, so as in some degree to com¬
pensate for the diminution of the perpendicular extent of

CONGENITAL DISTORTION OF SPINE.

357

this cavity ; more frequently, however, habitual dyspnoea,
especially on exertion, exists. Hypertrophy and other de¬
rangements of the heart sometimes result from mechanical
interference with its action; in more numerous instances
morbus cordis arises, from the constantly augmented efforts
necessary for increased propulsion of blood to compensate
for the diminished capacity of the lungs. Heart-disease
also follows a more rapid course. Subjects of severe spinal
curvature of any description are in later life martyrs to in¬
digestion, hepatic derangement, and hysteria [universal
hyperesthesia] (pp. 19 and 349). Constipation is likewise
a source of great annoyance.

Congenital distortion of the spine is comparatively rare.
Those extensive derangements observable in hemicepha-
loid and acephaloid foetuses, and in spina bifida, as they
possess no practical interest, and the subjects are seldom
viable, may be excluded from consideration. I have met
with cases requiring treatment in which the head was
retracted posteriorly, through shortening of the trapezius
and deeper cervical muscles. Tenotomy was not required
in these, the subjects having been young infants; but,
amongst other practitioners, M. Guerin has found section
of trapezius necessary. Nearly the whole of the distor¬
tions of the spine in infants are non-congenital.

358

LECTURE XVIII.

Distortions of spinal column analogous to contractures in other parts of
the frame—Spinal distortion from spasmodic and paralytic destruction
of equilibrium of spinal muscles ; [Spinal deformity from pleurisy ;]
from unequal length of the lower extremities—Ordinary lateral cur-
vat ur e—-Remote and proximate causes ; its nature and treatment ^—

[.Analysis of means of cure which have been recommended—Prevention
of spinal curvature]—Inapplicability of tenotomy as a means of curing
lateral curvature.

In the last Lecture, I described, as completely as the time
permitted, angular deformity of the spinal column, con¬
sisting of partial or complete ankylosis, being the condition
of the spine analogous to angular deformity and ankylosis
of a limb from inflammation, the result of scrofula or acci¬
dental injury. I also demonstrated the nature of rachitic
angular or posterior deformity, in which, you remember,
the column bends through want of firmness in its com¬
ponent parts, the hones, ligaments, and muscles. The
numerous models on the table illustrated the combination
of angular curvature from these causes, with a certain
amount of lateral deviation, angularity predominating.

I have in the next place to treat of those distortions
of the spinal column, which in their nature correspond
with contractures in other parts of the frame. Contractures
are those distortions which result from the operation of
causes which indirectly affect the articulations. You have
witnessed contractures of every articulation of the extre¬
mities induced by destruction of equilibrium in the mus¬
cles, from spasm on the one hand, or paralysis on the
other. We have studied the operation of burns, abscesses
in the soft parts, gangrene, and ulceration, in the produc¬
tion of contractures ; and we - can apply the information

PARALYTIC DEFORMITY OF SPINE.

359

thus derived to the comprehension of the deformities of the
spinal column. In the general remarks at the beginning
of the last Lecture I laid down the proposition that, having
in the spinal column bones, ligaments, and muscles, similar
to those in other parts of the frame, we should expect to
meet in the spine with pathological states.

Contracture of the hand and foot from spastic muscular
action is very common ; it may therefore be asked, Do
we observe spinal non-congenital deformity resulting from
spasmodic action of muscles ? In my opinion, very rarely.
Others have proceeded on the contrary assumption, and
have resorted to tenotomy of the spinal muscles as freely
as in the extremities. Stromeyer, the inventor of subcu¬
taneous tenotomy of tendo-Achillis, who first recommended
tenotomy in strabismus, was also the first to practise (anno
1835) section of spinal muscles. He operated in a case of
active retraction of the rhomboidei muscles, with which a
lateral inclination of the upper dorsal vertebrae was con¬
joined. But although the authority of Stromeyer con¬
firms the existence of non-congenital distortion from
abnormal activity of particular muscles, I believe that the
occurrence is exceedingly rare. Stromeyer does not, how¬
ever, like some other practitioners, regard ordinary lateral
curvature as the result of active retraction, the cure of
which they have attempted by tenotomy.

It may next be inquired, whether spinal distortion
results from paralysis of particular muscles. My friend
Stromeyer regards paralysis of the respiratory muscles as
the primary cause of ordinary lateral curvature.* I am
unable to agree with him on this subject. Observation has
convinced me that the debilitated condition of the inspira¬
tory muscles on the concave side of the chest in lateral
curvature is a secondary lesion. In well-marked cases of
partial paralysis of the voluntary muscles, affecting the
upper and lower extremities of one side, and of those mus-%
cles of the trunk on one side which are interested in the
* The author believes that this is no longer Stromeyer s opinion.

360

DISTORTIONS OF THE SPINE.

movements of the shoulder and hip, and attached to the
spine, even jn children, I have been surprised to witness
an absence of spinal distortion. In fact, excepting the
distortions which may affect the cervical vertebrae from
altered equilibrium of the muscles of the head and neck
(wry-neck), distortion of the spine from spasm or paralysis
of opposing muscles is exceedingly rare.

[Those of apparent distortion (see p. 112) may be
omitted from further consideration. The subject is here
mainly introduced for the purpose of illustrating the as¬
sertion that the spinal column is obnoxious to all the
causes of deformity which affect the limbs.

When, however, the paralysis of one or both sides of
the trunk is severe, the utmost deformity through collapse
of the trunk may result, the act of sitting unsupported
and that of locomotion being quite impossible.

The subject from whom the figs. 149 and 150 were

Fig. 149. Fig. 150.

Extreme paralytic spinal deformity viewed from behind and from the front,. The entire
abdomen touched the couch. It is almost unnecessary to state that the paralysis and
resulting deformity -were incurable.

taken was affected, with severe general paralysis of the
trunk and limbs during infancy. The power of the upper
extremities was recovered, whilst the trunk and lower ex¬
tremities remained flaccid and atrophic. Similar slighter
cases are narrated, p. 15.

Fig. 151 illustrates the same paralytic deformity when

DISTORTION SUCCEEDING TO PLEURISY.

361

the individual was supported beneath the arm-pits and
against the sides of the lower m g . isi.

ribs. It is in fact the position
which the patient could for a
short period daily assume in a
chair properly padded and ar¬
ranged for the purpose.]

Spinal distortion from burns,
wounds, attended with loss of
substance and subsequent ci¬
catrices, are rare, because the
spine is less exposed than the
members to accidental injury.

You can comprehend the man¬
ner in which cicatrices may dis¬
tort the Spine as Well as Other Model of the subject of figs. 149, 150 , when
. n , . 1 supported beneath the arm-pits.

regions of the body.

[The spinal and chest deformity which, as well in chil¬
dren as in young adults, succeeds recovery from pleurisy,
with effusion into the chest, requires mention here. De¬
formity thus produced appears to the casual observer si¬
milar to ordinary “ lateral curvature of the spineand
when slight, even the experienced eye may sometimes
hesitate in diagnosis. The dorsal curve in contraction
from pleurisy is more uniform, involves the whole dorsal
region, the depression of shoulder on the contracted side
is relatively greater, the reduction of capacity of the con¬
tracted side applies to the front as well as the back of the
chest, the posterior angles of the ribs on the expanded
side are less salient, and rotation of the vertebrae on their
horizontal axes is either entirely absent or very slight.

For many years the author was accustomed to regard
the deformity of the chest and spine after empyema as a
necessary and irremediable evil. Observation of the extent
to which burn-cicatrices may in favourable situations be
elongated, and the effect of exercise of the part in prevent-

DISTORTIONS OF THE SPINE.

ing recontraction and return of deformity, induced him,
three years since, to attempt removal of the incurvation of
chest and spine, which had occurred after empyema and
paracentesis thoracis in a child six years old, an in-patient
in the London Hospital. Before considering prevention
and cure of deformity of this nature, it is necessary to
reflect upon the causes which give rise to it.

Within the chest are the lungs long compressed by
pleuritic effusion, sometimes perhaps condensed by exu¬
dation into their texture, and more or less tough cellular
adhesions between the lungs and ribs, prone in the course
of time to become fibrous and to contract.

The protracted immobility of the affected side of the
chest places the intercostal muscles and the remaining
powerful muscles attached to the ribs, and distributed
over the chest, upon that side, in a condition favourable to
structural shortening (p. 13). As soon as any reduction
of the capacity of the affected side has taken place through
absorption or evacuation of the contained fluid, the tonic
contraction of these muscles comes more powerfully into
operation, their fibres shorten, the side of the chest may
even be compressed by them, or, at all events, they closely
follow the reduction of its dimensions. Structural short¬
ening of the muscles ensues after the same manner that it
is produced during repose of an articulation in a bent
position from disease. In fact, an analogy between the
mode of production of a contracted chest from empyema
and of a joint from inflammation exists.*

Reflection suggested that these deforming influences
might be counteracted, and that possibly none of them
could be considered insuperable obstacles to restoration.
The patient was caused to lie upon the sound side, with

* Pathologically, a chest and spine contraction after pleurisy is more
related to spinal distortion from disease (ankylosis); but morphologically
it is allied to lateral curvature, and for convenience is mentioned in this
Lecture.

ORDINARY LATERAL CURVATURE.

363

a broad band passed beneath this part, attached above to
the framework of the bed in such a manner as to cause
the trunk to be almost suspended in this lateral position.
The attachments of the band above the body were gradu¬
ally shortened, until the weight of the head and shoulders
above, and of the pelvis and lower extremities below,
powerfully drew asunder the contracted ribs and verte¬
brae. In short, the plan adopted was that recommended
for ordinary lateral curvature by Lafond, Shaw, and
Lonsdale.

The child was placed in this .position at first half an
hour daily, the treatment gradually lengthened to several
hours daily, and in a short time was cheerfully borne
during the whole time the child was not engaged in run¬
ning about for amusement. The beneficial effect of the
treatment was visible after a few days’ application of it;
and at the end of three months the reduction of defor¬
mity was so considerable, as to leave no doubt of the pos¬
sibility of obviating, at least in children, this serious ter¬
mination of empyema.*]

Inequality in the length of the lower extremities has
been assigned as a frequent cause of distortion of the spinal
column. I have several times witnessed lateral inclination
combined with actual difference in the length of the lower
limbs, as when the growth of one had been impaired in
childhood from scrofulous abscess in the leg and foot;
but I have examined no case in which, notwithstanding
the shortening, other causes of lateral curvature did not
exist. On the contrary, it is very remarkable, according
to my experience, that difference in the length of the
lower extremities is so rarely accompanied with deformity
of the spine, f Amongst many hundreds of cases ofconge-

* The models of the case before and after treatment are in the author's
possession, and are at the service of his medical brethren.

f The contrary has been often asserted. The conclusions on this
head, published ten years since, were based upon observation; and it is
useless to reason theoretically, that according to mechanical principles de-

364

DISTORTIONS OF THE SPINE.

nital and non-congenital spastic and paralytic deformity of
one foot, submitted to my examination, in which a diffe¬
rence of half an inch to several inches in the length of the
lower extremities existed, I have, with two or three ex¬
ceptions, not witnessed the concurrence of spinal curvature.
Some circumstances have operated in the exceptional cases
to produce the spinal curvature. You should be cautious
not to confound apparent with positive distortion. On
examining the back of a person having, for example, one
lower limb deficient one inch in length, you will frequently
remark that a serpentine curve in the vertebral column
exists; but on placing a book or other substance of the re¬
quisite thickness beneath the shorter limb, the curvature
of the spine will disappear* (see fig. 33, p. 112). It is a
fact of considerable importance in determining the causes
of these distortions, that shortness of a lower extremity
may exist during the twenty years preceding adult age

formity must ensue when one leg is shorter than another. This bending of
a point in pathology, easily proved by statistics, to suit a well-expounded
theory of mechanics, reminds one of the exclamation of Chirac, a French
writer on small-pox, “ C’est en vain tu resistes petite ve'role; je t’accoutu-
merai a la saignee.” The truth is, that with a vigorous healthy nutrition
of the spinal column, the tendency to deformity producible by a difference
in length of lower extremities is obviated by vigorous use of the back; but
when general debility, and weakness of the spinal column in particular, exists
from state of comparative inaction of the part, as in the modem mode of
rearing girls, an inequality in length of a lower extremity may act powerfully
as an exciting cause of spinal deformity. Well-marked rachitic subjects, who
have a considerable genu valgum, or other kind of shortening of one leg, are
very prone to lateral curvature of the spine.

It will be hereafter seen that the primary or predisposing cause of lateral
curvature is debility of the component parts of the column ; whilst inequality
of length of limb, certain occupations, use of particular parts, when pre¬
sent, are but secondary or exciting causes.

* The author’s statement of the infrequency of spinal deformity and
shortening of a lower extremity will be better understood by observing, that
he does not consider a curve in the back to be a deformity which is remov¬
able on equalising the length of the legs, or on placing the individual in a
straight position. Such a case is but a temporary malposition, often only
voluntary (see p. 112).

ORDINARY LATERAL CURVATURE.

365

without producing spinal deformity. Having rejected
spastic muscular action, paralysis, and inequality in length
of the lower extremities, as primary and ordinary causes
of deformity of the spinal column, you are prepared to
consider what is really the rationale of the production of
the distortion of the spinal column denominated lateral
curvature (scoliosis).* I shall not minutely examine the
modifications of this curvature which occur; as, when you
understand the ordinary form, you will, from your know¬
ledge of the anatomy of this region and of animal me¬
chanics, comprehend the origin of supplementary curves.
For the same reason, the treatment of a case in which
several causes exist requires to he conducted with re¬
ference to the primary distortion; if this he removed, the
secondary changes in form spontaneously disappear. You
perceive, in this series of models of ordinary lateral cur¬
vature, that the part of the column principally affected is
the dorsal region, and that, in the great majority, the verte¬
brae of this part incline from
the perpendicular position
towards the right side. For
a nearer appreciation of the
phenomena presented in this
deformity we will select this
severe case of a young girl,
thirteen years of age (see fig.

152). The peculiar charac¬
ter will be more evident than
if I take an example of
slighter deformity. You per¬
ceive that nearly the whole
of the dorsal vertebrae have,
in various degrees, yielded Severe ordinary lateral spinal curvature

/> . i i . t ,i viewed behind.

from the straight line, the

fifth, sixth, and seventh vertebrae being situated three inches
* Scoliosis habitualis, cko\i6u, to make crooked.

366

DISTORTIONS OF THE SPINE.

to the right of their proper position. The upper lumbar
and the lowest cervical vertebrae project towards the left.
The pelvis is situated obliquely, the left ilium greatly
elevated, whilst the corresponding shoulder is depressed,
the space between the axilla and ilium on this side not ex¬
ceeding five inches ; the ribs on this side are necessarily
in close contact with each other, respiratory movements of
the part being proportionately impeded. On the right
side posteriorly the ribs are altered in form, and, with the
scapula, form a large projection, the surface of which is
three or four inches above the plane of the remainder of
the dorsal region.

Anteriorly the deformity produced by severe lateral

Fig. 153.

spinal curvature is even more

considerable (fig. 153). In
the left anterior mammary
region the ribs are promi¬
nent. The head inclines for¬
wardly through yielding of
the upper part of the column,
the highest point of which
corresponds to the seventh
cervical vertebra. The re¬
sult of the large dorsal late¬
ral curve, and of the secon¬
dary curves, is a great re-

Severe ordinary lateral spinal curvature duction in the entire length
viewed in front. n , ,, ,

of the column; the lower

ribs are in contact with the ilia, through which consider¬

able diminution of the capacity of the abdominal cavity
results. In studying, then, the anatomical relation of
parts, you have to consider the diminution of capacity of
the thoracic and abdominal cavities consequent on the sink¬
ing of the vertebral column, the impeded development
of the left side of the thorax more especially, and the
obliquity of the pelvis. If you attentively study this series

SYMPTOMS OF LATERAL CURVATURE.

367

of models, you will notice that posteriorly the right side
of the thorax, and anteriorly the left side, project beyond
the plane of the contiguous part of the chest: this is only
explicable by observing that a movement of rotation of
the vertebras on their horizontal axes has taken place, the
articulating and transverse processes of the vertebras on
the right side being thrown backwards, whilst those on the
left side are thrust anteriorly. This abnormal rotation
constitutes the principal obstacle to the cure of severe
lateral curvature. Having thus described to you the se¬
vere form of the affection, you can hereafter in practice
have no difficulty in recognising it in the earlier stages;
the principal points being unequal elevation of the shoul¬
ders, especially of the scapulae, incipient prominence of
ribs on one side, and of the ilium on the opposite side.

Fig. 154. Fig. 155.

The uncommon example of
lateral curvature to the left
side.

[“ Lateral curvature of the spine” chiefly occurs on the
right side,* or, in other words, the convexity of the dorsal
curve is to the right, as in fig. 154; although, as shewn in

* Biihringf confirms the observations of Desruelles, Petreqnin, and Hyrtl,
that in the healthy and robust, besides the normal antero-posterior curves, a
distinct thoracic curve of the spine to the right exists. This is attributed to
the spinal column being unequally loaded at the sides in different parts,—on

t Die seitliche Ruckgrats-Verkriimmung, von Dr. J. J. Biihring: Berlin, 1851.

368 DISTORTIONS OF THE SPINE.

the model, fig. 155, it sometimes occurs towards the left
side.]

I will now endeavour briefly to explain my opinion of
the mode of origin of this lateral curvature. In the last
Lecture I demonstrated to you that when the bodies of
one or more vertebrae are destroyed by scrofulous or other
forms of vertebral disease, the strong muscles of the spine
cannot advantageously resist the falling forwards of the

the left, in the dorsal region, by the heart and great blood-vessels, and on the
right by the liver. The ordinary dorsal curve in lateral curvature he proposes
to term “ cardiac curve,” and the ordinary lumbar curve “ hepatic curve.”
Besides the mere effect of relative over-loading of the sides of the column,
Biihring, remembering the influence exercised during the developmental period
by the arteries upon their contiguous parietes, even when bony, is of opinion
that the heart and aorta obtain an increase of space by impelling the dorsal
vertebrae to the right; whilst the liver and its vessels similarly dispose to the
lumbar curve. A full account of the ingenious and scientific views of Biihring
explanatory of the origin of lateral curvature from its prototype, a physio¬
logical state, would require more space than can be here devoted to the pur¬
pose. The author is by no means convinced that a “ cardiac” or a “ hepatic”
curve does naturally exist; and, on the other hand, he is not prepared to
deny that a curve requiring a more precise measure of a straight or curved
line than the eye can appreciate may exist. The examination of a number
of adults and children unaffected with distortion, taken indiscriminately, has
satisfied him that no obvious natural lateral curves, such as Biihring describes,
are present in healthy persons.

In the course of this investigation he has observed that the spines of
healthy male children, about the age of ten or twelve, appear straight, per¬
fectly free from lateral deviation. It is difficult in younger children to
determine the point, as such individuals are not readily induced to remain
still under examination, or to refrain from such movements of the trunk as
interrupt careful observation. The author found that the dorsal region of
young men, from the age of eighteen to twenty-two (the subjects were of the
working class, in-door hospital convalescents), often presented irregular de¬
viations of one or more spinous processes of the upper dorsal region. One
spinous process, for example, often that of the second dorsal vertebra, de¬
viated more than half an inch to the left, whilst the spinous processes of the
third and fourth vertebrae inclined beyond the median line to the right. The
cause of these displacements of single vertebrae in this region, which bear no
resemblance to “ ordinary lateral curvature,” remains a subject for future
inquiry.

ORIGIN OF LATERAL CURVATURE. , 369

column, hence a posterior projection of the region, deno¬
minated angular curvature. In like manner, when all the
component parts of the spine, bones, ligaments, and muscles,
are deprived of their proper firmness and tone in rickets,
the spinal column, incapable of maintaining itself erect and
of withstanding the influence of the weight of the thorax
and the contained organs, which naturally tends to bend it
forwards, yields, so that an angular or posterior curvature
results. But in less severe rickets, or when constitutional
debility exists, or when a child or young female is simply
said to be delicate, the organisation of the more lowly or¬
ganised structures, the bones and ligaments, suffers in a
greater degree than the muscular system. The muscles of
the spine participate in the debility; but they remain sus¬
ceptible to application of the stimulus of volition, they are
throughout the day instinctively occupied in the mainte¬
nance of the erect posture. This ability, sufficiently to
react against the natural tendency of the thorax to incline
anteriorly, prevents posterior curvature; but the same mus¬
cles do not possess sufficient power to prevent the operation
of lateral displacing influences. That during the produc¬
tion, or in existence of lateral curvature, the efficient action
of the spinal muscles is capable of explaining the absence
of posterior curvature of the dorsal vertebrae, is shewn by
the remarkable concavity which sometimes exists in the
middle dorsal region. I have witnessed severe lateral cur¬
vatures in young females who were particular in their
endeavours to maintain the perpendicular position of the
spine by drawing inwards the dorsal and lumbar vertebrae
and throwing the shoulders backwards. But as the firm¬
ness of the osseous and white fibrous structures of the spinal
Column is impaired in debilitated or delicate individuals,
and the tendency to posterior yielding is resisted by the
yet comparatively powerful spinal muscles, if any cause
capable of disturbing the equilibrium of the powers which
laterally maintain the perpendicular line of the spinal

370

DISTORTIONS OP THE SPINE.

column be applied, the result will be a lateral deviation.
The rarity of lateral deviation of the spine, even in delicate
boys, is well known; it appears to me to be equally un¬
common amongst the children of the poorest classes of
society, who are notwithstanding frequently affected with
posterior curvature. But in females of the richer classes
whose time is much occupied in sedentary amusement and
instruction, and in those of the poorer classes who obtain
their livelihood by sedentary employment, in over-worked,
over-grown, and badly-fed boys, who labour at manufac¬
tures in which particular parts of the body are more ex¬
cited to activity than others, spinal lateral curvature may
be produced. It is apparent that the curvature is preceded
and often accompanied by an imperfect nutrition or im¬
perfect assimilation of food, diminished vigour and power
of the nervous system, either from hereditary influence or
from disproportionate abstraction of nervous energy from
the animal and vegetative functions of the system and ex¬
penditure thereof upon the intellectual. Very many young
women, of large stature and otherwise well developed, be¬
come the victims of lateral curvature from “ outgrowing
their strength,” as it is termed; or, more strictly speaking,
from the necessities of the system being insufficiently sup¬
plied by proper digestion and assimilation of food, out¬
door exercise, and amusement. These are the remote
causes of every case of lateral curvature; the exciting
cause correctly assigned by the majority of writers on the
subject being the undue exercise and development of the
muscles attached to the ribs and spinal column of one side,
subservient to the movements of one upper extremity,
usually the right.* I have already remarked that the spine
is liable to be influenced, particularly in youth, by every
movement of the extremities; when the remote cause of

* Doubtful etiology may be determined by presence of analogous affections.
Spurious valgus, or flat-foot (p. 231), often co-exists with lateral curvature,
and, like it, is more common in the female than in the male sex.

ORIGIN OP LATERAL CURVATURE.

371

spinal curvature, — debility, however produced,—exists,
the spine is disposed to yield; and the direction in which
it will yield will be determined by the nature and mode
of operation of the exciting cause. When the right upper
extremity is disproportionately exercised, an undue trac¬
tion upon the dorsal portion of the spinal column takes
place, succeeded by an inclination to the right side. When,
therefore, the equilibrium between the muscular powers
which laterally support the column is once destroyed, the
increase of lateral inclination is rapidly effected, through
the co-operation of numerous other inj urious influences. Of
these, particular positions of the body, as in writing, draw¬
ing, sewing, may favour the deformity. The habit of rest¬
ing the weight of the frame, whilst standing, almost entirely
on the right lower extremity, is calculated greatly to facili¬
tate increase of the curvature.* The normal lateral move¬
ments of the spine become impeded on occurrence of mor¬
bid inclination to one side ; hence those muscles affixed to
the ribs and spine which effect these lateral movements are
thrown out of exercise. Those situated in the concavity
of the curve or curves being relaxed, gradually contract,
and become ultimately structurally shorter; those on the
convexity of the curve being in the first instance stretched
or elongated, become ultimately debilitated and powerless.
The total length of the column being diminished, the mus¬
cles which are principally concerned in preventing flexion
of the column become in time structurally shorter, through
the approximation of their points of origin and insertion.
This structural shortening of muscles tends rapidly to in-

* The exciting cause of excessive use of one arm or leg is insufficient to
produce distortion, without the constitutional relaxation of bones, ligaments,
and muscles; if it were, lateral curvature should always occur in paralysis of
one side of face, arm, trunk, and leg. The author has seen a child grow up to
manhood with complete hemiplegia, without trace of lateral curvature. Werner
relates a similar case. The author, when the above Lectures were written,
attached more importance to excessive use of right arm than it merits. He has
also seen many dorsal curves to the left in persons who were not left-handed.

372

DISTORTIONS OF THE SPINE.

crease the curve during the period of the growth of the
frame. For as the muscles cease to be exercised, they do not
keep pace in growth with the development of the skeleton;
the individual bones of the column continue to enlarge, but
as the muscles are structurally shorter, the addition to the
aggregate length of the spinal column, consequent on the
enlargement of the individual bones, cannot take place in
a straight line, and the curve is consequently increased.

The constitutional debility attendant upon lateral cur¬
vature may continue during the entire period of the aug¬
mentation of deformity; often towards puberty an improve¬
ment is manifest; but in many cases, after a few years, the
health again gives way, and the increase of deformity be¬
comes a source of renewed anxiety. The appearance of the
catamenia is usually deferred, and confirmed chlorosis oc¬
casionally coexists. In slight lateral curvature the health
may appear unaffected to a superficial observer, or to some
parents, who are more willing to attribute the deformity
to an accidental cause than to constitutional disturbance.
As I have already observed, the general disturbance, when
slight, may be comprehended in the expression of the in¬
dividual having outgrown her strength. In many cases the
remote cause—debility—is too apparent to be overlooked,
as when the deformity appears during convalescence from
measles, hooping-cough, or other disorder of childhood.

When speaking of posterior curvature from rachitis, I
alluded to its occasional combination with lateral deviation;
I should also remark that lateral curvature, when severe, is
usually complicated with posterior yielding of the column.
The remote causes of the lateral and posterior curvature
(from debility or rachitis) differ only in the degree of consti¬
tutional affection. If the latter be comparatively slight, the
spinal muscles, which in health maintain the erect position
of the trunk, prevent posterior curvature, but are incapable
of preventing the column being unequally acted upon and
drawn laterally by preponderance in the use of certain

TREATMENT OF LATERAL CURVATURE.

373

muscles. When the constitutional debility is so great that
the spinal muscles are incapable of preventing the anterior
flexion of the column, posterior curvature results.

I have sufficiently swelled the catalogue of primary and
secondary evils resulting from these deformities, indepen¬
dently of the mere disadvantage arising from being de¬
formed, to urge you to study well the means of affording
relief. When consulted in these cases, you will proceed to
treatment, not only with the view of effecting a beneficial
change in form, but with the gratification of endeavouring
to relieve a physical infirmity, and at the same time avert
a series of lesions dangerous to life.

[The intractable nature of a disease being usually in pro¬
portion to the number of remedies proposed for it, a glanee
at the numerous means devised by the ardour, ingenuity,
and industry of successive generations of orthopaedic prac¬
titioners for “ the cure of lateral curvature of the spine” will
shew the difficulty of removing this distortion when fully
established. They are all referrible to the following heads:

1. Improvement of the general health.

2. Mechanical supports or scaffoldings.

3. ,, compression of lapsed parts.

4. „ elongation of the whole trunk.

5. Surgical division of contracted muscles.

6. Recumbency.

7. Gymnastics.

8. Automatic exercise of particular muscles.

9. „ rectification of equilibrium of the column.

10. Topical application of medicines.

11. Electricity.

1. Improvement of the general health is necessary in
all cases in the early stage, in many cases during the en¬
tire progress of the deformity, and, in some who may have
previously become comparatively robust, at any period of
the deformity, through the operation of causes connected
with or foreign to it. In the child mere debility may ap-

374

DISTORTIONS OF THE SPINE.

pear to exist, or a feeble digestive or nervous system may
require attention. Sometimes, at a later period, amenor-
rboea or chlorosis is present. It has been asserted that the
health and constitution of the subjects of lateral curvature
are perfect.* This is only true of the later stages,f when,
analogously to that which is sometimes observed after re¬
covery from general rachitism, the person not unfrequently
enjoys excellent health. It is unnecessary to detail the
means of effecting the indication here presented. The prin¬
ciples of treatment consist in employment of a nutritious
diet, tonics, gentle laxatives, suitable air and exercise.

2. Mechanical supports or scaffoldings . These means
have been as much condemned by some medical men as
their advantages have been extolled by others. An un¬
prejudiced experience of many years of cases treated with
or without their use justifies the assertion that they neither
merit the praises lavished by some nor the anathemas of
others. Too much has been expected of them. They are
not adapted to the removal of the primary causes of la¬
teral curvature; they cannot therefore be employed as
curative means. As a scaffolding or a buttress may sup¬
port an inclined building, in like manner a well-adjusted
mechanical support may prevent further yielding in the

* Werner.

+ Four stages of lateral curvature may be conveniently discriminated :

1st stage, that in which the spinous processes of the dorsal vertebrae de¬
viate from 1 to 2 lines from their position.

2d stage, in which the whole trunk deviates to the right to the extent that
a plummet suspended from the seventh cervical vertebra will deviate an inch
from the medium line of the sacrum, the scapulae and left hip being already
considerably displaced.

3d stage, rotation of vertebrae upon their long axes, absorption of their
bodies on the concave side of the curves, shortening and organic changes in
the ligaments, fibrous or adipose degeneration of muscles, may now have taken
place. The deviation of the trunk to the right is not necessarily greater in
this than in second stage; but the deformity of ribs anteriorly and poste¬
riorly is greater. Extension in the long axis of the trunk scarcely effects
even temporary improvement of form.

4th grade is no longer a lateral curvature, but a gibbosity; the right
dorsal protuberance extends three or four inches beyond the left side of chest,
the left axilla is close to ilium, and left intercostal spaces are extinguished.

SUPPORTS IN LATERAL CURVATURE.

375

improper direction. — may prevent increase of deformity—
may arrest the evil at the stage at which the machinery
is. employed. But even this admission of their utility is
qualified by the results of experience, which shew that
many lateral curvatures continue to increase in spite of
instruments apparently well-adapted to the intention with,
which- they have been employed. The causes of their failure
frequently consist in some inherent imperfection, in the
want of constancy in.their use, their liability to shift in
their adjustment through the continuous growth of the
patient, and alterations in the character of the curvature.
Numerous special writers on lateral curvature have de¬
scribed their respective instruments, the principle of all
mere supports or scaffoldings to the trunk consisting in
making the projecting hip-bone on either side, and the"
sacrum behind, the resting-points for the machinery to be
erected for the support of the trunk. The pieces of ma¬
chinery used for this purpose are usually a band of metal,
leather, or similar material, to encircle and rest upon the
pelvis; “ crutches,” that is, metallic or wooden pieces ex¬
tending from the pelvis to the arm-pits; a back-piece, with
or without branches, properly fastened to receive the pres¬
sure of the spine or of the lower ribs on one or both sides.
Such is the apparatus more or less allied in its structure
to the ordinary ladies’ corset, and, like it, incapable of
cure and often of prevention. Some of the older practi¬
tioners added to this contrivance a piece upon which, by
means of chin and occipital straps, or by the intervention
of metallic clasps, the head rests. An attempt is thus
made to extend support to the head as well as to the
trunk. The spinal support, with the head-prolongation,
was termed the Minerva, and probably fell into disuse
from its having been employed with curative, that is, a
mistaken object, instead of being used as a potent auxi¬
liary means of preventing transmission of pressure or weight
to the ground or seat through the weak vertebral column,

376

DISTORTIONS OF THE SPINE.

and because its use is unsightly. With the limited hut irn-
^ portant objects un¬

doubtedly attainable
from a support, the
Minerva (fig. 156) is
a valuable means to
be used in lateral
curvature. It is par¬
ticularly serviceable
in the second stage
of the deformity,
when the mischief is
inclined rapidly to
progress ; and as the
subjects are usually
during this stage
young, the objection
of its unsightliness is
inapplicable. Even
the principal part of
the unsightliness is
removable by the
metallic parts being
properly covered,
and by the habili¬
ments being suitably

A light, efficient spinal support for lateral curvature during a( J a pJ; e d to it. If the
the remediable stage, with head-piece or “the Minerva” tr
attached. The head-piece is removable. Two straps admission be made
of india-rubber material are attached to this piece, one c

to receive the chin, the other to pass under the occiput, that the aggregate Ot
the structure called
the spine is weak in lateral curvature, or that when an
abnormal curve in it has in any manner been produced,
the greater the weight borne by the lapsed column, the
greater will be the tendency to increase of the curve, it
follows that it is desirable, when assumption of the erect
posture is permitted in the rapidly-increasing stage of this

MECHANICAL COMPRESSION IN LAT. CURV. 377

deformity, to remove if possible the weight acting as a
cause of the augmentation of deformity. Moreover, late¬
ral curvature is particularly prone to occur in weakly sub¬
jects, who enjoy a larger cerebral development, and who
present a more slender figure than others. Sturdy chil¬
dren rarely become the subjects of this distortion.

3. Mechanical compression of lapsed parts. At all times
recourse appears instinctively to have been had to mechan¬
ical pressure against the convexities of the several curves
offered by the distorted column. This compression or pres¬
sure has been exercised in various modes, as by the hands
of a strong attendant, by pads, screws, or springs attached
either to mechanical supports or to couches, recumbent
frames, and beds ; sometimes by suspensory straps, as de¬
scribed p. 362. But although common sense suggests em¬
ployment of this means, experience demonstrates that its
usefulness is only in proportion to the youthfulness of the pa¬
tient, or the earliness of the period at which it is employed;
and that after the deformity is confirmed and the tissues
have become inelastic through age, it constitutes a means
unequal to the end. It may, however, be used as an
auxiliary to other means; and if constantly used, a slight
amount of pressure does exercise a greater influence in re¬
placement than might be expected from the small amount
of power employed. An objection to its use is, that when
applied to the part where it is most indicated, viz. to the
ordinary dorso-costal protuberance, the whole of the force
employed is not, as intended, directed against the sides of
the lapsed vertebrae, through the intermedium of the ribs
attached to the oblique and transverse processes; but owing
to the elasticity of the ribs in young subjects, the power is
mainly expended at the angles of the ribs, the ordinary
prominence of which in lateral curvature is often thereby
increased. Compression, by means of an instrument of iron
or wood, against the convex side of the spinous processes of
dorsal vertebrae has been much but ineffectually employed

378

DISTORTIONS OF THE SPINE.

for the removal of the peculiar rotation of the vertebrae on
their horizontal axes, which constitutes so insuperable an
obstacle to restoration in the advanced stages. Compres¬
sion of the spine and ribs by means of the “ shield” of the
late Dr. Harrison, used in the recumbent posture, which
consists of a broad thick wooden splint, may be carried
to so great an extent as to obliterate the natural antero¬
posterior curves of the dorsal and lumbar regions. The
author, in consultation with Mr. Norwood of Hastings,
saw a patient, of the susceptible age of eleven, who had
been thus deformed for life by intended curative efforts.

4. Mechanical elongation of the trunk has been employed
in a variety of ways. The simplest mode has been the act of
swinging by the hands from a cross-bar, suspended at each
end from the ceiling. This swinging has been expected
to act beneficially through the weight of the inferior part
of the trunk and of the lower limbs depending from the
dorsal vertebrae, being calculated to elongate the ligaments
and muscles upon the concave side of the curves, and
temporarily to release the corresponding sides of the bodies
of the vertebras and intervertebral substances from the un¬
due compression to which they are subjected in the de¬
formed state. During the act of swinging, so long as the
muscles of the trunk are actively influenced by the will,
little or no straightening effect upon the column will be
exercised. The patient must swing passively as far as the.
back is concerned, or the muscles of the back need to be
fatigued before they will permit by this means any straight¬
ening effect upon the spine. Nevertheless it will be found
on examining patients whilst thus engaged in swinging,
that the weight of the shoulders being transmitted to the
cross-bar is removed from the dorsal vertebrae, and that
so long as this is the case the position of the spine is better.
It is, however, not a reliable means in well-marked defor¬
mity; it is more beneficial during the earlier stages, and
derives its principal efficacy from its partaking of a gym-

SUSPENSORY APPARATUS—EXTENSION-BEDS. 379

nastic exercise. Mechanical elongation of trunk has also
been attempted by a variety of other suspensory apparatus;
the patient, for example, having been suspended by the head
in a suitable framework, without the feet being allowed to
touch the ground. Many representations of this apparatus
are to be found in orthopaedic works. It is a sufficient con¬
demnation of this proceeding to remark, that the connec¬
tions of the upper cervical vertebrae with the cranium are
less firm than those of the lapsed dorsal and lumbar verte¬
brae with each other; and that consequently a moderate
amount of hanging will rather tend to separate the atlas
from the occipital bone than cure deformity; besides which,
cases are actually recorded of injury and disease of ligaments
of cervical vertebrae having been produced by it. As if to
solicit danger, some orthopaedists, not content with simple
suspension by the head, the weight of the trunk and members
constituting the measure of the extending power, have
added weights of 20 or 30 lbs. to the feet to increase the
effect of the suspension. Heine practised suspension by the
head combined with sea-bathing, the person being let down
from a ridiculous cumbrous wagon, and allowed to practise
a sort of gymnastics in the water. Extension in the hori¬
zontal position has been even more widely practised: it has
been conducted harmlessly compared with the rude suspen¬
sion above described. Innumerable extension-beds have
been invented, furnished with straps to fix the head, and
contrivances for fulfilment of the indications followed un¬
der the third head of means used; the objections to any
energetic attempt horizontally to elongate the trunk would
be almost as great as the hanging process above described.
The only benefit obtainable from an extension -bed is that
the patient is, even by the gentle application of its power,
excited if not coerced into quiet retention of a position
desired by the attendant. The designing and manufacture
of racho-orthopaedic extension-beds have been carried to
an extraordinary degree of intended completeness. One

DISTORTIONS OF THE SPINE.

knows not whether most to admire the ingenuity which
has enabled the inventor to adapt his couch to every pos¬
sible modification of distortion, and to fulfil on the one bed
every mechanical indication, or to lament that so much
talent has been expended principally with the result of
merely influencing the imagination and the confidence of
the sufferer or her friends.* Besides extension-beds and
extension - perpendicular - suspending frames, extension-
chairs have been employed; the patient undergoing per¬
pendicular elongation from the head whilst the pelvis rested
upon and was secured to a chair. Their effects may be
classed with those of other active stretching apparatus. A
less formidable proceeding, much employed by some au¬
thors, has been that of causing the patient to take exercise
upon common crutches only. By this means the lower part
of the spinal column is relieved of the weight of the shoul¬
ders and arms, and is thereby straightened; but little benefit
is exercised upon the more important dorsal curve. The
influence of the weight of the head upon that part of the
column which it especially and primarily influences, viz.
the upper part, is not modified by this proceeding. Loco¬
motion upon crutches may, however, be advantageously
practised in those cases of lateral curvature in which, whilst
exercise in the open air is desirable, the laxity and flexibility
of the column is so extreme, that every time the upright
posture is exercised, the ligaments and muscles upon the
convexities of the curves are injuriously elongated, whilst
the intervertebral substances and bodies of vertebras on
the concave sides are compressed; and consequently the
benefit derivable to the bodily health from out-door exer¬
cise is neutralised by the injury inflicted upon the vertebral
structures.

5. Surgical division of contracted muscles. Racho-my-
otomy has been extensively practised by some orthopaedic

* See particularly the profusely illustrated work of Humbert.

MYOTOMY—RECUMBENCY.

381

practitioners, under the erroneous idea that lateral curva¬
ture is chiefly dependent for its maintenance upon active
retraction of certain muscles, and that section of the con¬
tracted parts would liberate the distorted vertebras. Ex¬
perience has amply demonstrated that this operation is
fruitless. Unlike tenotomy of the limbs, spinal myotomy
is not even capable of being successfully performed even
in a mechanical point of view ; for the spinal muscles, un¬
like the majority of muscles in the limbs, are not gathered
into considerable tendons, the division of which relaxes
a large amount of muscular fibres, but consist of large
numbers of small muscles, not running in the aggregate a
free course, but attached beneath to every osseous salient
point; hence section of spinal muscles is followed by com¬
paratively little separation of divided parts, and after heal¬
ing of these re-contraction ensues, and leaves the parts as
before.

6. Recumbency recommends itself as a natural means
of avoiding fatigue and strain upon weak parts during the
early stage of lateral curvature, often as a means of im¬
proving the bodily health (p. 388), and sometimes as a
pis aller when the practitioner has witnessed failure of
the means employed to arrest the progress of deformity,
and concludes that at all events the distortion will not
advance so long as the recumbent attitude is maintained.*
When not immoderately prolonged, it is the simplest and
safest of ortho-rachitic means, and may advantageously
form at least a part of the treatment of every case. The

* Recumbency tends at least to prevent or diminish the compression of
vertebral bodies and intervertebral substances ; an organic change which con¬
stitutes so great a drawback to recovery. The following is an analysis of loss
of height of vertebral column on the concavities of the several curves in a se¬
vere lateral curvature (4th grade), according to Cruvelhier ( Werner, p. 105).
—Four curves existed: 1, a slight cervical curve to the left, the measurement
of which was purposely omitted; 2, a dorsal curve to the right, involving the
dorsal vertebrae from the third to the eleventh inclusively ; 3, a lumbar curve
to the left, involving the twelfth dorsal and four upper lumbar vertebrae;

DISTORTIONS OF THE SPINE.

decubitus may be dorsal, prone, or lateral; often the
position may be varied, according to the inclination of
the patient and the nature of the occupation or amusement
in which she may be engaged. The position will also he
selected according to the extent or nature of other ap¬
pliances (Nos. 3, 4, and 7) to be used during recumbency.

Gymnastics (p. 29) may be either general, that is,
when voluntary exercises are employed with the general
object of exercising and developing the whole frame; or
special, when, according to preconceived views of the etio¬
logy of lateral curvature, particular parts only are exer¬
cised. Gymnastics have been much abused; young females
having been excited to athletic feats and exertions bene¬
ficial or necessary only for the development of the frame
of the male sex. They have been pushed to a dangerous
extent, as when undue fatigue and exhaustion have been
consequent upon them. It is now well known that ex¬
cessive muscular exertion in youth has something lethal
in its consequences. Even when not pushed to this ex¬
treme, impairment of nervous system, loss of appetite,
debility of digestive system, often result. In the early
stage of lateral curvature, every means calculated to
strengthen the nervous system, augment the digestive and
assimilating powers, is needed; and as extreme use of gym-

4, a sacral curve to the right, involving the fifth lumbar vertebra and the

sacrum.

Aggregate loss of height on the concave side of the bodies

of nine dorsal vertebra;.5| lines.

Ditto on the corresponding intervertebral substances . 11J „

Ditto on the bodies of five vertebrae in lumbar curve .21 ,,

Ditto corresponding five intervertebral substances . . I7i „

Ditto on fifth lumbar vertebra.2 ,,

Ditto on intervertebral substances between the fourth and
fifth lumbar vertebra; and that between fifth lumbar
vertebra and the os sacrum.3J ,*

Total.6l£ lines.

LATERAL CURVATURE — GYMNASTICS.

nasties produces contrary effects, it should be avoided.
At the same time, it is well known that whilst excessive
muscular exertion produces injurious consequences, the
moderate use of the same means effects directly the con¬
trary. Swimming is one of the best preventives of lateral
curvature, and a most beneficial gymnastic exercise.*

Moderate, light, easy gymnastic or calisthenic exercises
are of the utmost advantage in the early stage of lateral
curvature, the primary or remote cause of which is con¬
stitutional debility,—-a state so apt to he overlooked by
the inexperienced; and the secondary causes of which are
ungainly lax attitudes unavoidably assumed by the weak
individual—occupations and positions either unsuitable to
the age and condition, or daily assumed during too large a
portion of time.

The normal growth and development of every part can¬
not take place unless every muscle and part of the frame
undergo a suitable amount of use. It would be superfluous
to occupy time in proving that often, in modern education
and rearing of young people of both sexes, many muscles
and parts can never be adequately exercised. Moderate
and proper gymnastics supply this defect in education.j'

Suitable games and gymnastic exercises in the open air,

* In no respect are the labours of our profession more certain of suecess-
fnl results than in the incessant efforts made to enlighten society on the pre¬
vention of disease. This is an important field of usefulness, not neglected
even in relation to deformities : witness a work of Mr. Hare, at present ad¬
vertised, on the prevention of lateral curvature.

t It is right to observe, that the undoubted increase of lateral curvature
during the last half-century has produced greater attention to the necessity of
corporeal exercises to young females, and in the best scholastic establishments
moderate gymnastics form a part of education. The dietary, the hours of re¬
pose, and recreation, still require amendment in many pensionnats which have
come under the author’s notice. One of the first requisites a parent should
inquire for in determining the eligibility of a school, is the existence of large
play-grounds, for the absence of which “ long walks” are not sufficient com¬
pensation. Experience has taught many parents that sacrifice of health,
strength, and figure are lamentable drawbacks to the highly-finished education

384

DISTORTIONS OF THE SPINE.

when practicable, relieve the mind of the anxious, scrupu¬
lously attentive girl (the most apt to become deformed) ;
they quicken the blood circulation — distribute it more
equally to the extremities, surface, and internal parts; in¬
crease the activity of movement of contents of alimentary
canal, favour defecation, and effect other physiological pur¬
poses upon which it is unnecessary to insist. The effects,
already narrated, obviate some of the prominent symptoms
of a weakly constitution. Many lateral curvatures in the
first stage are entirely corrected by moderate general gym¬
nastics.

Special gymnastics consist of the artistic and habitual
exercise of particular parts with the view of augmenting
the power of particular muscles. These special gymnastics
are more specious than real, inasmuch as it is often im¬
possible to set in action certain muscles without involving
others during the movements effected. A common example
of special gymnastics is the preferential or exclusive use of
the left arm, recommended with the idea of augmenting the
power of the muscles which connect the left scapula with the
spine and ribs, and thereby drawing the lapsed dorsal ver¬
tebra towards the left side. This extra use of the left arm
is combined with the endeavour to swing by it alone by
means of the common hand-swing (p. 378). Over-confi¬
dence in the efficacy of special gymnastics is founded upon
too exclusive a reference to excessive use of right arm as
a cause of lateral curvature. The turning of hand-wheel
machinery, or the working of a pulley, either in the erect
or recumbent position, is a piece of special gymnastics
serving sometimes the double purpose of developing the

and accomplishments acquired by ten or twelve hours of assiduous devotion
to studies for two or three years at a “ finishing” establishment. The evils
resulting from premature and too-continued excitement of intellect and erro¬
neous management are more to be regretted, as, with judicious arrangements,
accomplishments and the highest order of education are compatible with reten¬
tion of health and strength.

TREATMENT OF LATERAL CURVATURE. 385

contracted side of the chest, and furnishing a certain exer¬
cise and employment during the monotony of protracted
recumbency.

The Swedish exercises, which have gone the round of
northern Europe, do not merit favourable mention; they
are attended by a certain class of evils which approximate
them to the so-called mesmeric passes, on the same level
with which they may he placed. Any good they can realise
may be obtained from the manipulations of a rubber or
nurse.*

8. Automatic exercise of particular muscles. The ob¬
servation of the effects of carrying weights upon the head
in perfecting the normal development of the figure, and
causing an erect stature in water-carriers in tropical coun¬
tries, appears to have suggested the idea that benefit would
be derived from increasing the weight to be borne by the
spinal column. The proposal to carry a book or a weight
upon the top of the head has been adopted as a means of
straightening a laterally curved spine. The proposition
already advanced, that the tone of the muscles and ligaments
of the vertebral column is impaired previously to and during
the early stage of lateral curvature, and that the larger the
cranial development, the greater is the liability (all other
things being equal) to lateral curvature, and the advantage
of temporarily withdrawing the weight of the head, indicate
the author’s opinion, that however useful the carrying a
burden upon the head may be in the development of a
healthy organism, it is objectionable during the continu¬
ance of the deformity in question. Moreover, the utmost
proportional or physiological development is attainable
without adding to the weight of the head. The head
alone is the weight properly adjusted to the condition of
the spine by the Artificer of all things. The constant
carrying of an additional weight by the health}* individual

* Reform, der Orthopedie. Werner: Berlin, 1851.

DISTORTIONS OF THE SPINE.

would develop the neck and shoulders beyond the normal,
and remind one of the brawny figure of the porter,-—pre¬
cisely as ladies’ arms may by immoderate gymnastics be
made to resemble those of the dairy-maid. Brown’s hori¬
zontal lever-belt may be reckoned amongst the means cal¬
culated to effect automatic exercise of particular muscles.
Disuse of an arm or foot acts not only through the volun¬
tarily increased activity of the employed member, but also
automatically. Even the crutch employed in many sup¬
ports (see Mechanical Supports, p. 375), resting below upon
the left ilium, and extended to the arm-pit, when made
longer than the ordinary distance from the axilla to crista
ilii, is supposed to induce automatic activity of muscles
proceeding from the scapula to the spine, and thus tend to
draw the lapsed dorsal vertebras, towards the left, into a
right position.

It has been proposed to effect automatic exertion of
the muscles of the left or reduced side of the chest by
compelling the patient to lie on this side, or by placing a
heavy weight on his side. By this means it has been
hoped, expansion of the side being impeded, that greater
efforts of inspiration in the part would ensue. This plan
is contrary both to reasoning and experience.

The treatment of the deformity after pleurisy (p. 362)
proves that lying upon the protuberant side of the chest
causes increased efforts at inspiration and expansion of the
collapsed or contracted side.

9. The automatic rectification of equilibrium of the column
may sometimes be effected; as when the legs are of unequal
length, and the spine temporarily or constantly distorted,
the practitioner places an additional heel or a book beneath
the shortened member, by means of which the spontaneous
rectification of the column proceeds from below upwards.
The extra heel leads to elevation of the depressed side of the
pelvis, the lumbar curve is partially or completely effaced,
and successively those of the dorsal and cervical regions.

TREATMENT OF LATERAL CURVATURE.

387

Allied to this means is the acquirement of the habit of rest¬
ing the body upon the limb opposite to that generally em¬
ployed by weakly children. It is worthy of remark, that
lounging, idle corporeal habits of youth, besides the evi¬
dence afforded of ill-regulated mind, are often a sure index
of physical disorder, either of direct weakness, or of indi¬
rect debility from overloaded alimentary canal, constipa¬
tion, errors of diet, want of relation between the hours of
repose and exercise, &c. The mind is often, therefore*
but secondarily affected.

10. The topical application of medicinal agents, such as
embrocations, lotions, saline solutions, sea-water, hold a
subordinate place in therapeutics, and their modus operandi
and precise value do not require consideration in this place.

11. Electricity. The small estimation in which this
potent agent should therapeutically be held has already
been alluded to when treating of the means generally appli¬
cable to deformities, p.45. Like the majority of paralytic
and spasmodic deformities, though proceeding from a dif¬
ferent source, lateral deformity of spine is not merely a
local affection, and therefore it is not capable of being
cured by a merely local remedy.]

The indications of treatment of lateral spinal curvature
may be arranged under three heads: the first in importance
consists in endeavouring to remove the primary cause of
the deformity—debility, by improving the constitutional
powers of the individual; in the second rank may be
placed the application of mechanical means adapted to pre¬
vent the increase and to remove existing deformity; and
the third indication consists in application of means to act
dynamically on the spinal column, such as exercises.

It is unnecessary to devote more time to a description
of the measures calculated to improve the general health:
food in proper quantity and quality, good air, moderate
bodily exercise, the exhibition of steel, iodine, vegetable

388

DISTORTIONS OF THE SPINE.

tonics, and laxatives, according to the peculiarities of in¬
dividual cases. In very severe cases occurring at the
period of life when the general growth should be most
.rapid, particularly if very great debility he present, you
may for a time forbid exercise altogether. In these cases
the patient should have the benefit of carriage-exercise, or
in the summer season be permitted to recline in the open
air during a large portion of the twenty-four hours. En¬
tire suspension of corporeal exercise is highly prejudicial
to persons in vigorous health, and has consequently been
commonly considered equally inexpedient to persons de¬
bilitated, as in severe spinal curvature. The cases of per¬
sons in health and debility widely differ. The debilitated
individual possesses little vigour to expend; if this he ex¬
hausted in corporeal exercise, none will remain for the
due performance of the vegetative functions of the system.
.You will often be surprised to observe that a person ex¬
tremely weak, labouring under spinal curvature, who has
dong struggled to improve her health by exercise and nu¬
tritive diet, continues daily to get worse, until entirely
confined to the couch, after which a manifest improve¬
ment in every function ensues. Do not mistake the im¬
port of the advice I now offer you. Use entire repose in
these instances during a limited period, as a means of
improving the general health. It may be advantageous as
a means of fulfilling the second indication, which I shall
presently consider. Do not imagine that I recommend a
confinement of months and years to the recumbent posi¬
tion as a means of curing spinal curvature.

The means of fulfilling the second indication (the ap¬
plication of mechanical means adapted to prevent increase
and remove existing deformity,) will be more intelligible if
you reflect on the physical condition of the spine. You
.perceive a weak column, unable, through want of firmness
and tone, to support itself in the erect position, daily
yielding from the perpendicular line, through the combined

TREATMENT OF LATERAL CURVATURE.

389-

influence of gravity and unequal muscular traction. You
further observe, when the curvature is not of long standing,
that the column is straightened on the assumption of the
recumbent position. Is it not proper, under these circum¬
stances, greatly to abridge the period during which the
erect posture is attempted to be maintained, and thus be 1
content to follow the course pursued by many nurses or
parents who perceive a child’s spine to bend beneath the
superincumbent weight ? Undoubtedly the most certain
plan would be to confine the patient during the whole of
the remaining years of growth, with the hope that if the
column remained straight, or nearly so, at the period of
completion of growth, it would not subsequently yield.
This is an important part of the plan adopted by a gentle¬
man now deceased, whose zeal in behalf of humanity and
science is proved by the legacy of a large sum of money for
the treatment of sufferers from spinal disease. Dr. Harri¬
son, to whom I allude, attributed too much, in my opinion,
to the adjuvant means contained in his “system," and too
little to the influence of mere repose. I shall sufficiently
discountenance absolute repose during long periods, as one
of the means of curing lateral curvature, when I state that,
in Dr. Harrison’s hands, seven years did not always suffice,
for the attainment of his object; and that when persevered
in during a much shorter period, the wasting of the mus¬
cular system generally is so considerable, that fears may
reasonably be entertained that recovery therefrom may
never be effected. According to the urgency of the case,,
you may, however, have recourse to recumbency during
four or six hours daily, divided into two or three portions.

The necessity of relieving the column of as large a
portion of the superincumbent weight as possible is ge¬
nerally acknowledged. Numerous spinal supports and:
corsets, invented by their manufacturers with the specific;
property of curing lateral spinal deformity, have, at all
periods, been brought under the notice of the profession*

390

DISTORTIONS OF THE SPINE.

Some of these inventions, on the contrary, enjoy a dis¬
honourable privacy; their nature, if not their merits, being
carefully concealed. The greater number of them answer
in some degree the purpose of supporting the spine, being
applied whilst in the recumbent posture; they resemble
a cuirass or scaffold, against which the tottering or inclined
spine finds a resting point. They are, as already shewn, not
curative, and rarely prevent increase of deformity. Springs
similar to a hernia-truss are often applied, through the in¬
tervention of the ribs, to the proj ecting parts of the co¬
lumn ; but their utility does not equal the ingenuity of their
application. Hossard’s lever-belt, incorrectly termed Ta¬
vernier’s, which I have for some time past employed, with
some modifications,* approaches more nearly to a scientific
apparatus for cure of lateral curvature than any other I
have examined (see fig. 7, p. 34). The mode of operation
of this apparatus in rectifying the position of the spinal
column is simple. The pelvis affords a fixed point, so that
the traction exercised upon the upper extremity of the
lever by means of the laced belt acts powerfully and con¬
tinuously, during all the movements of the frame, in com¬
pressing the ribs of the right side, and through their in¬
tervention, propels the lapsed dorsal vertebrae into the per¬
pendicular position. The restoration may be facilitated
by the weight of the upper extremities being partially
removed by the addition of crutches. This apparatus
possesses the advantage of not subjecting the thorax to
any circular compression ; the wasted left side of the tho¬
rax is perfectly free, and one of the earliest signs of im¬
provement consequent on use of the apparatus is an evi¬
dent enlargement of the capacity of this side. The relief
experienced [from this apparatus, or from the Minerva
and other well-adapted supports] is so great, that patients
spontaneously remark the diminished fatigue with which

* The strap to pass beneath the pelvis, or the heel, is not mentioned in
Tavernier’s account of Hossard’s apparatus.

TREATMENT OF LATERAL CURVATURE.

391

they take exercise, and the greater freedom with which
they respire. I have witnessed no instances in which the
health of the patient has not at the same time improved.
It is unnecessary to remark, that in the use of all me¬
chanical contrivances for the relief of deformities, as much
will depend upon the manner of application as upon the
apparatus itself. Do not hastily attempt too much, but
gradually accustom your patient to its use. It is well to
remember the maxim, arte non vi, in this as in other de¬
formities (p. 37). Benefit may also be derived by causing
a shoe with raised heel to be worn on the side on which
the ilium is depressed. It counteracts the habitual sink¬
ing of the side through the improper attitude instinctively
assumed. It rectifies the position of the pelvis, and com¬
pels the spinal column to attempt, as it were, its own res¬
toration (p. 386).

Manipulations, frictions, suitable exercises, modified
calisthenics, as they are termed, by which the muscles of
the upper part of the frame, particularly those of the left
side, may be excited to activity and strengthened, serve
to fulfil the third indication. , It is necessary, however, to
guard against too great exertion or fatigue. By judicious
application of the principles I have laid down, and by avail¬
ing yourselves of the practical hints I have given you, you
may, in the majority of spinal lateral curvatures of not
more than three or four years’ duration [as at the age of
from ten to fifteen], succeed in re-establishing the straight
line of the spinal column.* It is more difficult to remove

* Lateral curvature of the spine is essentially a chronic affection ; its pro¬
gress,—from the slightest want of correspondence of the hips or shoulders, and
an amount of deviation of the spinal column imperceptible to the ordinary eye,
to that stage in which one shoulder and subjacent ribs form an unsightly dor¬
sal protuberance, the opposite axilla reaching to within a hand’s-breadth of the
corresponding hip,—occasionally occupies a period of many years. In the
majority of cases the weakness is during several months entirely overlooked.
During another period of several months, the simplest means of ameliorating
the figure are resorted to, such as attention to attitude, gymnastic exercises,

392

DISTORTIONS OF THE SPINE.

the deformity of the ribs; those on the right side of the
thorax are absolutely larger than those of the left, which
have been imperfectly developed, through the distortion
having so long existed during the growth of the body.
They are not only larger but altered in form, and no
means exist by which they can be wholly restored. This
circumstance is of little moment beyond the traces pre¬
sented of former spinal distortion, as proper arrangement
of female dress and the skill of the corset-maker may
conceal it. The principal object, straightening of the
spinal column , being obtained, relapse of the form of the
trunk, and the secondary evils of spinal curvature formerly
enumerated, need not be apprehended.

Any surgical operation is unnecessary for the cure of
moderate curvatures, and is ineffectual in the more severe
forms of the deformity.

I will add an extract from the work of Stromeyer,
TJeber Paralyse der Inspirations-Mushelm , and apply it to
the views promulgated in these Lectures: “ With the con¬
clusion of these remarks the question may be asked: Whe¬
ther these pathological notions will facilitate the cure of
lateral spinal curvature ? I believe I may answer in the
affirmative, provided they tend to excite an interest in the
study of this affection among medical practitioners; for
the majority of these have hitherto spurned the investiga¬
tion and treatment of these complaints, and have preferred

and the recumbent position. These means are often successful; but very
frequently the mischief proceeds unchecked, or even becomes visibly aggra¬
vated. Sometimes the occurrence of indisposition, or a severe illness, with¬
draws attention from the minor evil of deformity until after convalescence,
when it is found that, with greater general debility, the deviation has advanced
with an accelerated pace. In like manner, the evil often appears stationary
for months, or the increase escapes the watchful eye of the parent, rendered
incapable of correct appreciation of the matter by too-frequent contemplation
of the object. It is then a disorder of months and years’ progress and dura¬
tion, and, like all chronic affections, admits but of proportionately slow re¬
covery.

TREATMENT OF LATERAL CURVATURE.

leaving them to the shoemaker and machinist. The early
recognition and successful treatment of lateral curvature
can only he effected by a general diffusion of clear ideas
of its nature. A correct pathology will exercise little in¬
fluence upon cases of many years’ duration, as these are
incurable; hut they may be alleviated, or their progress
arrested,—a fact which neither the public nor practitioners
have sufficiently recognised.”

[The cases in which the cervical curve is slight or alto¬
gether wanting,—in which the column is still flexible,—
in which the deviation diminishes when the patient assumes
the prone position,—in young subjects, in whom the growth
of the frame is incomplete, and in whom the general health,
although weakly, is free from any decided constitutional
disease,—are those in which treatment is most successful.
These, indeed, are the cases for which the numerous plans
of treatment advocated from the time of Andry to the pre¬
sent day are available. Much benefit from their use even
in advanced cases is witnessed, although cure is unattain¬
able. The attempt to cure inveterate cases of lateral cur¬
vature, if at the suggestion of the scientific and philosophic
mind, can only end in disappointment; if at the prompt¬
ings of the dishonest pretender, in painful delusion and
victimising of the unfortunate sufferer. In incurable cases
muck may be effected in preventing further physical de¬
gradation of the spinal column, and of the important organs
of the chest and abdomen dependent upon tbe adequate
protection and support of tbe spine for tbeir proper func¬
tions.]

APPENDIX.

Stkabismus. —The eye is so delicately poised between the differ¬
ent muscles within the orbit, as to render it liable to be drawn
from its proper position by the slightest deviation in the normal
action of the internal or external recti. A transient or permanent
deformity of congenital or non-congenital origin may thus be in¬
duced in the position of the eye, consisting either of an inward or
outward inclination of the globe, commonly known as convergent
and divergent strabismus.

The pathology of this affection is of interest in connexion with
many of the deformities mentioned in this work (p. 106, &c.), both
as illustrating how spasmodic action of a muscle may be the result
of derangement either in the brain or spinal cord, or through the
incident nerves, and how such a contraction may be relieved by
mechanical means after the source of abnormal muscular action
has been removed; and further, it points out how a weakened
muscle may be elongated and overcome by a more powerful an¬
tagonist, which, in its turn, becomes structurally shortened.

The treatment, though necessarily modified according to the
nature of the part, is the same in principle as that adopted for the
cure of many other deformities. Thus we find that spasmodic
action is relieved, first, by removing the cause, when practicable,
and then by applying what may be said to represent the mechani¬
cal treatment in other cases, namely, by the use of darkened spec¬
tacles with central apertures, so as to keep the eyes in their
proper position, or occasionally by covering the sound organ,
while the distorted one is carefully exercised in the necessary
movements in order to re-balance, as it were, the affected muscles.

Structural shortening of one of these muscles requires the
same operation that has been recommended as necessary to relieve
similar contractions in other parts of the body. And here Stro-

398

APPENDIX.

meyer’s subcutaneous section of a tendon finds its counterpart in
tbe subconjunctival method of dividing the internal rectus, such
as is now generally adopted at the Ophthalmic Hospital in Moor-
fields and elsewhere.*

This last operation is somewhat more difficult of performance
than the usual one, which consists in freely dividing the con¬
junctiva at a proper distance from the cornea, and then in pass¬
ing a bent probe, or a small curved director, with a good sweep
from below upwards and outwards so as to glide well between the
tendon and the sclerotic ; the muscle may then be brought forward
and divided, either with scissors or by means of a bistoury,
curved according to the fancy of the operator.

The subconjunctival method requires the head to be well sup¬
ported by an assistant, and the eyelids to be widely separated by
a self-acting speculum. If the patient cannot rotate the globe
outwards, an assistant had better nip up the conjunctiva on the
outer side of the cornea, so as to draw the eye into the necessary
position. The operator then seizes the conjunctiva between the
forceps, above half an inch internal to the cornea, and a quarter
of an inch below the horizontal section of the eye; a small open¬
ing is then made with narrow probe-pointed scissors, so that a
properly curved blunt hook may be easily inserted and passed, as
directed, above, in order to get well between the muscle and the
globe. The scissors may next be inserted through the superficial
opening, and made to nip carefully through the structures raised
on the hook beneath the conjunctiva. After dividing as much as
is deemed requisite, not forgetting the bands of cellular tissue
which sometimes interfere with the success of the operation, the
hook may be withdrawn, and the position of the eye examined.
If the direction of the globe is in any way deformed, the hook
had better be reinserted so as to endeavour to bring forward
within the reach of the scissors any other contracted fibres to be
divided.

* Stromeyer was the first to propose the application of tenotomy or myo¬
tomy for the cure of strabismus, and received a prize of 4000 francs from the
French AcadSmie de Mddecine for the discovery. Dieffenbach received a
sim il ar prize for having been the first to carry Stromeyer’s proposal into

STRABISMUS—RELAPSED CASES.

397

By adopting this subconjunctival plan of division, the patient
is not only secured from the exuberant fungus which sometimes
results when the conjunctiva is more freely divided, but the eye
does hot afterwards present the same sinking-in on the inner side
of the globe and of the caruncula, which can be observed when
the former method has been adopted. —(Gowlland.)

On relapsed or neglected Cases. —It was the author’s intention
to have added some full details of the treatment required in differ¬
ent forms of deformity which have either relapsed after the resto¬
ration was far advanced, or which have been so neglected during
the treatment as to constitute cases of incomplete restoration. The
subject is one of much importance to the credit of orthopaedy, and
especially of tenotomy, for the cases are numerous in which the
fruits of this operation have been lost from different causes. The
length to which this work has already extended precludes any thing
further than brief allusions to the more pressing cases which
present themselves in consultation. The author’s experience of
relapse embraces many cases treated by himself several years ago.
Thus, although the great majority of the cases appended to his
Treatise on Club-foot , 1839, have remained “cured,” No. 2, for
example, has required repetition of the operation, but is now an
active cavalry officer. No. 12 has needed much attention. No. 16,
in which recovery appeared perfect, as shewn by the woodcut
attached to that work, suffered relapse in one foot and repetition
of section of T.-Achillis, with division of anterior and posterior
tibial tendons. The subject of this case subsequently became
affected with hemiplegia, one of the few instances the author has
witnessed of the occurrence of a direct disease of nervous centres
after congenital Talipes. No. 18 partially relapsed, but recovered
with the aid of manipulations and instrumental treatment, and is
now a robust, active man. No. 23 subsequently occasioned much
trouble, owing to the cicatrix of the slough, which had resulted
from pressure against cuboid portion of the involuted sole. No.
32 is alluded to here for the purpose of stating, that although
treated without operation, the cure has continued perfect, the sub¬
ject being at present actively engaged as a student of medicine.

Some of these references to cases treated by the author pre-

398

APPENDIX.

viously to 1839, and many others that have fallen under his notice,
will suffice to shew that these observations on the causes and the
mode of rectification of relapsed or neglected cases are not super¬
fluous.

A formidable cause of return of deformity after treatment, con¬
ducted with or without operation, is, that whilst the elongated
muscles and tendons are, from more or less protracted duration of
the deformity, inferiorly organised and grow less than unaffected
parts, the bones and the muscles upon the uncontracted side of the
member having been but slightly, or not at all, implicated in the
original cause of the distortion, grow at a greater pace; and thus
the mode of progress of the acts of nutrition favours a disproportion
between the length of the moving parts (the muscles) and between
one portion of the latter and the moved parts (the bones).

This natural tendency of deformity to return can only be ob¬
viated by the similar course necessary in any disease, viz. by the
medical practitioner taking care not to regard a case as “ cured’’
so long as a trace of contraction remains, and by sedulous use of
means used for the “ cure,” viz. active and passive exercises, and
sometimes by retentive apparatus.

It was natural that the promulgation by Stromeyer of subcu¬
taneous tenotomy, by means of which as great benefit is obtainable
in a few weeks as was formerly attainable in adults even after
several years’ assiduous use of instruments, should lead to the hasty
employment of operative means by surgeons unprepared for the
after-treatment. Besides which, the aid obtainable from simple
division of one tendon was often believed to be sufficient even in a
complicated deformity. Confidence in subcutaneous operation, and
its application to several tendons affecting one articulation, has been
progressive on the part of those who have specially devoted them¬
selves to the treatment of deformities. Such persons now, in the
treatment of T. varus of average severity, for example (p. 295),
divide not only the Achilles tendon, but also those of the anterior
and posterior tibial muscles. If the practitioner, from the belief
in the sufficiency of section of one tendon, or from the want of
greater operative experience, omit division of the latter muscles
in cases in which their section is requisite* he may find that in
spite of depression of the heel, he has not fully removed the in-

RELAPSED CASES.

. version of foot, and consequently he may witness partial recurrence
of deformity.

Eelapse of varus is oftener directly due to omission, by the
parents or the patient, of proper active and passive exercises. The
author recommends as a rule in relapsed cases, that re-operation
be not indiscriminately employed. He has witnessed many un¬
promising cases, operated months and years previously, which
have promptly yielded to mechanical and manual treatment.

Whenever the belly of the muscle is observed to be retracted,
and the tendinous portion disproportionately long, the practitioner
may safely determine that the maintenance of the deformity is due
to shortened ligaments, or altered articular surfaces, and that re¬
petition of operation is quite unnecessary. These observations are
suggested by relapsed varus, but apply to numerous deformities in
other parts of the body.

The author has been consulted in cases in which the condition
of a patient has been aggravated by unnecessary operations, espe¬
cially in paralytic or spastic deformities. The structural shorten¬
ing in such cases is with comparative facility overcome, whilst
operation cannot give power to paralysed parts, and is only useful
as an exception in active spasm, the relief of which must be sought
in means which fall under the province of the physician. An
operation has frequently converted such cases into deformity of a
different kind.

Eetentive Apparatus (see also p. 47) may often consist of the
mechanical means employed for the primary treatment of the
deformity. Such apparatus is commonly too cumbrous or un¬
sightly for locomotion, but is frequently available when it is desir¬
able to use it during a portion of the day or the night only.

A brief description of the contrivances the author has introduced
for some of the more common deformities will suffice to exemplify
this subject, as, when the orthopedic student has acquired a know¬
ledge of the application of a mechanical principle to one mem¬
ber or part of the body, he will be enabled to apply it to other
parts.

Thus, after foot-deformities, when the anterior muscles of the
ankle-joint have not yet obtained the power of balancing the pos-

400

APPENDIX.

terior muscles, or -when recontraction of posterior muscles is to
be avoided, a simple instrument like that represented fig. 157 is
applicable. A projecting stud or screw
is inserted at the ankle-joint, against
which a corresponding prolongation
of tbe iron inferiorly is made to stop,
when elevation of tbe beel is attempted.
When free motion of tbe ankle is de¬
sired, tbe same boot is available upon
removal of tbe screw.

In tbe opposite class of foot-defor¬
mities, when tbe weakness resides in
tbe posterior muscles (calcaneus, cal-
caneo-valgus), tbe same contrivance is
available, if tbe position of tbe screw
be reversed, i. e. placed behind tbe
inferior prolongation of tbe iron in¬
stead of being in front of it.

A mode of effecting tbe principal movements wanted in any

Fig. 158 .

The endless screw as ap¬
plicable to numerous or¬
thopaedic apparatus.

apparatus for varus is added, fig. 158. Tbe
German orthopedists bave long employed this
power— the endless screw —as a means of ex¬
tension. Tbe fig. represents tbe ankle-portion
of a supposed varus instrument. By tbe endless
screw opposite tbe ankle, flexion or extension
of tbe ankle at will is obtained; by tbe similar
screw above tbe ankle-joint, placed in tbe op¬
posite direction to tbe first, elevation or de¬
pression of tbe margins of tbe foot is obtained.
Tbe author several years since was indebted
to Dr. Brown of Boston, U.S., for a specimen
of a complete instrument for varus, in wbicb
tbe endless screw was introduced so as to effect
tbe three movements required in varus, viz.
depression of tbe beel, depression of inner
margin, and eversion of tbe toes.

This instrument becomes a useful reten¬

tive apparatus when motion of tbe ankle is for a time undesirable:

RETENTIVE APPARATUS.

401

but in consequence of its not permitting any voluntary movement
on the part of the patient, it is for the general purposes of varus
decidedly inferior to those represented in figs. 118, 119.

Experience shews that it is highly objectionable to maintain
a limb 'many days and weeks in any instrument without manipu¬
lations or passive movements (pp. 37, 99). A certain mobility in
a proper direction permitted to the patient tends to obviate the
evil. The author has seen a varus too long left in an instrument
(locomotion perhaps having been effected,) converted into a rigid
calcaneo-valgus.

The endless screw is also useful on account of its great power
as a means ofworking” a joint “upwards and downwards” when
manipulations are desirable, and no competent rubber is at hand
for the purpose.

Fig. 159.

402 APPENDIX.

Figs. 159 and 160 are added for illustration of forms of reten¬
tive apparatus employed at the knee (made by the Fergusons,
Giltspur St.) ; the first is available in the frequent case of de¬
bility of anterior muscles of the knee. The patient, by means of
the spring there shewn, is permitted to bend the knee in walking,
Fig. i6i. whilst the weak muscles are aided

in stiffening the knee so as to pre¬
vent prosternation. The second (fig.
160) is applicable where locomo¬
tion with a stiff knee is for a time
desirable, the spring-catch enabling
the patient to bend the joint in the
act of seating himself without excit¬
ing the attention of others.

Fig. 161 exhibits a simple means
of graduating the angle of the foot
with the leg, and may be inserted
almost unseen in a common boot.

The length to which this book has
i already extended prevents fulfilment
of the author’s purpose of inserting
in the Appendix some other matters to which allusion has been
made in the text.

INDEX.

Abscess, contracture from, 173.

Ablation of os cuboides proposed, 305.
of part of tendo-Achillis condemned,
163.

Achilles tendon, contraction of, 88, 152,
259.

Adams, of Lymington, case, 175.

Adams, W., 277.

Dr., 318.

Adipose degeneration, 15.

Aitken, Dr., case, 198
Allen, Mr., case, 40.

Alteration of temperature, symmetry, 16.
Analogues with spastic rigidity, 118.
Anatomy of genu valgum, 211.
of ankylosis contractures, 128.
of congenital club-foot, 271-281.
of non-congenital club-foot, 135.
of posterior tibial tendon, 298.
Anaesthetics in deformities, benefit de¬
rivable from, 43.

Angular and lateral strumous deformity
of spine, 343.

and posterior deformity of spine, 354.
contraction of knee, 75.
distortion of spine, 341; treatment,
354.

terminations of, 348.

Ankle, incomplete ankylosis of, defor¬
mity from, 88.
true ankylosis of, 87.

Ankylosis, deformity from complete, 50.
diagnosis of deformity from, 55.
difficulties in treatment, 59.
from rheumatism, 53.
from scrofula, 53.
in straight position, 72.

Ankylosis, mild measures more successful
in treating, 62.
of elbow, 98.

of hip, deformity from, 65.
of hip, false, 67.
of hip, true, 68.
of fingers, 100.
of knee, 71.
of wrist, 102.
origin of, 50.
partial, 50, 52.
prevention of, 73.
stages of treatment, 63.
treatment of, 58.

Anterior tibial, division of, 302.

Apparatus, retaining, 47, 399.

Apparent spinal deformity, 112.

Arte non vi, secret of success in cure of
deformities, 391.

Arthur, Mr., case, 175.

Articulations in contracture, 129.

Articular surfaces, displacement of, 54.
re-,adaptation of, 216.
restoration of, 23.

Artificial Talipes calcaneus, 168.

Associated muscles, contraction of, 109.

Asphyxia neonatorum, deformity from,
114.

Atresia, 327.

Atrophy of fingers, 330.
of leg and foot, congenital, 328.

. of muscles, 14.

Automatic exercises, 385.

Barrett’s instrument for opening the
mouth, 177.

Barton’s operation for ankylosis of Mp, 64.

404

INDEX.

Baths, value of, in deformities, 27.
Beribery, 147.

Billing, Dr., 127.

Blumenbach, etiology of varus, 24.

Bones, changes of, in deformities, 17.
Bones, restoration of form, 24.

Boyer, 242.

Brodhurst’s instrument for wry-neck,
note , 324.

Brodie, Sir B., 192.

Biihring’s views of spinal curvatures,
note , 367.

Burn-contractures, treatment of, 125.
Bumble-foot, see Varus.

Calcaneus, 157; see also Talipes cal¬
caneus.

artificial (Chinese), 168.
from ruptured T. Achillis, 166.
from section of T. Achillis, 166.
from paralysis of T. Achillis, 166.
mechanical treatment of, 164.
Calcaneo-valgus congenitus, 312.
artificial, 401.

non-congenital, objections to ablation
of portion of T. Achillis, 162.
treatment of, -165.

Calcaneo-varus, 172, 307.

Caries at elbow, 99.
of vertebrae, 343.

Causes of congenital distortions, 252.
Causes of rachitis, 203.

Cervical fascia, diseased, 182.
Chaissagnac, 195.

Chalk-stones, 100.

Character, influence of deformities on, 18.
Chance, statistics of deformities, 225.
Children, lounging habits, cause of, 387.
Chloroformisation in stiff joint, 60, 240.
Chloroform, value of, in diagnosis, 43.
Chorea-like distortion, 113.

Cicatrices, deformity from, 194.
Classification of deformities (author’s) 11.

of malformations by Henle, note, 325.
Clonic hand spasm of children, 187.
spasm incompatible with much struc¬
tural shortening, 140.

Club-hand, 247, 320.

Club-foot, causes of, 242, 251.
opinions of earlier writers concerning:
Duverney, Boyer, 242; Scarpa, Jorg,
Rudolphi, 243 ; Delpech, 244; Cru-
velhier, 246; Tourtual, 248; Philip
von Walther, 249; Dr.Pockels, 250;
Stromeyer, 250; Maisonnahe, Gue¬
rin, Duval, 251.

Dr. Little’s shoes for, 292.
morbid anatomy of, 271, 278.
mechanical cure of, 285.
operative treatment of, 293.
Glissonand Camper on, 271; Blumen¬
bach, Naumburg, Wanzel, Bruckner,
Scarpa, Jorg, 272 ; Clossius, Colles,
Mackeever, 273; Palletta, Delpech,
Cruvelhier, Lob, 274; Tourtual,275;
Weis, Adams, 277 ; B. Bell, 278'.

Coalitio partium, 326.

Coates, Martin, 295.

Cold douche, 28.

Colies, 273.

Compression of lapsed parts, 377.
of vertebral bodies, 382.

Complete ankylosis, diagnosis of, 55.

Congenital atrophy of leg and foot, 328.
calcaneo-valgus, 312.
calcaneo-varus, 307.
distortions, 9, 262, 316, 318, 322.
distortions, etiology of, 241.
distortions of spine, 357.
distortions of upper extremity, 320.
distortions, general, 314.
equino-valgus, 311.
luxations, causes of, 317.
luxations, symptoms of, 318.
luxations of knee forwards, 319.
malformations, 324, 338.
paralysis, 122, 316.
sub-luxation of knee backwards, 319.
sub-luxation of wrist, 322.

Talipes equinus, 259.

Talipes varus, 261.
valgus, 309.

varus, completeness of recovery, 304.
varus, external characters of, 263.

INDEX.

405

Congenital varus, extreme, 267.
varus, indications of tenotomy, 293.
varus, mechanical apparatus, 290.
varus, mechanical treatment of, 281,
289.

varus, progress of, 264.
varus, proper time for replacement,
305.

varus, splints for, 286.
varus, secondary changes, 269.
varus, state of limb above, 270.
varus, three grades of, 303.
varus, varieties of, 265.
wry-neck, 322.

Contracted finger from spasm, treatment,
183.

finger from wound, 182.
hand from rheumatism, 100; treat¬
ment, 101, 179.
knee, 75.

palmar fascia, pathology, 180.
palmar fascia, 179; treatment, 181.
toes from flat-foot, 97.
toes from improper shoes, 96.
toes from rheumatism, 94 ; treatment,
95.

Contraction, temporary or constant, 12.
of associated muscles, 109.
deformities from, see Contractures,
transient, 12.

Contractures, 103.
and idiocy, 187.
from bums, 194.
causes of, 104.
common origin of, 128.
from asphyxia at birth, 116.
from cicatrices after suppuration, 172.
from disease of fasciae, 178.
from habitual retention in one posi¬
tion, 175.

from impaired nutrition, 146 ; origin
sometimes acute cerebro-spinal, 147.
from injury of nerve, 128.
intermitting, 12, 186.
from premature birth, 114.
gradual or sudden, 111.
in general, treatment of, 136.

Contractures, meaning of, 9, 103.
morbid anatomy of, 128.
of arm, treatment of, 154.
of maxillae, 176.

paralytic of lower extremities, 149.
reflex, origin sometimes, 106.
simultaneous, 110.
spasmodic, 106.
tenotomy in, 137.
the articulations in, 129.
universal tetanus-like, 113.
with feeble intellect, 115.

Cooper, Sir. A., on division of plantar
fascia, note, 5.

Coulson, 97.

Critchett, case of varus, 306.

Cruvelhier, 246.

Curling, malformations, 331.

Curvature of bones, from other causes
than rachitis, 236.
how caused, 222.
lateral, of spine, 365.
tenotomy in, 228.
treatment of, 230.
of vertebrae, 339.

Curves, supplemental, 342.
angular, of spine, 343.
posterior, of spine, 352.

Curvature of spine, paralytic, 14, 360.

Cyllopoda, cyllosis, see Outward Curva¬
ture of Legs.

Cyphosis, 343.

Debility, deformity from, 11,202,369.

Deformed toes from flat-foot, 97.
toes from improper shoes, 96.

Deformities, changes in muscles, joints,
and ligaments, 17.
classification of (author’s), 9.
congenital, 239.
hereditary, 179, 308.
importance of study, 2, 5.
influence of, on sound parts, 17.
influence on health, 19.
of spinal column, 339, 342, 350.
modes of termination and secondary
evils of, 349.

406

INDEX.

Deformity, paralysis not in proportion
to, note, 347.

from asphyxia neonatorum, 114.
from badly united fracture, 40.
from burns, 194.

from causes directly affecting the arti¬
culations, 8.

from causes indirectly affecting the ar¬
ticulations, 9.
from osteo-malacia, 227.
from disease of fascia, 178.
from debility, 9.
from paralysis, 120.
from rheumatism, 53, 94, 100.
from scrofula, 53, 75, 79.
from spasms, 106.
in hands of mechanics, 180.
inflammation a frequent cause, 8.
modes of arranging, 7.
not neglected by the ancients, 3.
pathology of, 6.
prevention of, 49.
relative frequency, 10, 117, 225.
rachitic, 11, 204, 208.
rachitic causes, 205.
treatment of, 25.
with incomplete ankylosis, 88.
Degeneration, adipose and fibrous, 14.
Delpech, 5, 244, 274.

De Morgan, 98.

Diagnosis of various forms of wry-neck,
191.

Dieffenbach, 264.

Dieffenbach’s plan of treating knee anky¬
losis, 61.

of unreduced dislocation, 98.

Diet of infants, 204.

Diseased cervical fascia, 182.

foetal organism, 247.

Dislocation of shoulder unreduced, 98.
Disorder of foetal nervous system,
249.

Displacement of articular surfaces, 54.
Distortions of spine, analogous to con¬
tractures in other parts, 358.
from paralysis, 359, 360.
spasmodic action of muscles, 359.

Distortions of spine, inequality in length
of lower extremities, 363.
Distortions, causes of congenital, 243,
252.

from maternal impressions, 253.
from mechanical influence, 255.
from walls of uterus, 255.
from umbilical cord, 256.
co-existence of several, 251.
congenital, 239, 316, 322.
congenital, causes of, 243, 252.
exciting causes, 8.
external resemblance of, 6.
from disease of spinal cord or brain,
106.

influence of, upon character, 19.
of front of chest in consequence of an¬
gular curvature of spine, 344.
of spine, 342, 352.

from strumous disease, 342 ; difficulty
of diagnosis, 347; favourable termi¬
nation of, 348.
origin of, 19.
rachitic, 202.
relative frequency of, 10.
secondary evils of, 18.
succeeding to pleurisy, 361; author’s
treatment of, 363.

Division of resisting structures, 45.
anterior tibial, 302.
flexors of fingers, 180.
muscles of eye, 395.
posterior tibial, 93, 297.
sterno-mastoid, 322.
tendons in knee ankylosis, 81.
Dupuytren, 4, 40.

Duval, 308.

Duverney, 242.

Eburnation, 24, 237.

Equilibrium between muscles, restoration
of, 24.

automatic rectification of, 386.

Elbow, caries of, 99.
stiffness of, 98.
tenotomy at, 99.

Entanglement of limbs in utero, 256, 334.

INDEX.

407

Electricity seldom applicable, sometimes
injurious, 47.

Equino-valgus, 169,' 311.

Equino-varus, 106, 142.

Equinus, paralytic, 152.
anatomy of, 134.
congenital, 259.
spastic, 106.

Equilibrium of spine, rectification, 386.
Erysipelas, deformity from, 76, 172.
Extension, evils of protracted, 27, 99.
when inapplicable, 43.
forcible, with chloroform, 42, 240.
Extent of paralytic contracture, 121.
Etiology of congenital distortions, 241,
308.

of contractures, 105.

of lateral curvature of spine, 368.

of rickets, 203.

Extreme varus, ablation of os cuboides
in, 305.

varus, apparatus contrived by author,
292.

varus, forcible means in, 306.
Excurvation of spine, 352.

Exercises, automatic, 385.
gymnastic, 382.
passive, see Manipulations.

Swedish, 385.

False ankylosis of hip with luxation,
67.

Farish, Mr., 14.

Fascia, deformity from disease of, 178.

hypertrophy and induration of, 105.
Fatty degeneration, 14.

Feeble intellect, contracture with, 115.
Fingers, rheumatic contraction of, 100.
contracture of, 179, 183.
deficiency of, 331.
hypertrophy and atrophy of, 330.
spasm of, 184.

Fissures, abnormal, 326.

Fistula colli congenita, 326.

Flat-foot (valgus spurius), 231.
three stages of, 233.
treatment of, 234.

Flexors of foot, which are they, physio¬
logically, 110.

Foot, congenital malformation of, 332.
board, Stromeyer’s, for equinus, equi¬
no-varus, and equino-valgus, 290.
Forcible extension, 41.
evils of, 61.

Fracture, deformity from, badly united,
40.

Freeman, Dr., case, 173.

Fusion of bones, deformity from, 326,329.

Gay, Mr., 132.

General congenital distortion, 314.

spastic rigidity, statistics of, 117.
Gentle treatment, value of, 39.

Genu valgum, 209.

valgum, anatomy of, 211.
valgum, curvature of bones in, 210.
valgum, is tenotomy necessary ? 221.
valgum, mechanical treatment of, 220.
valgum, treatment of, 212, 218.
Gibbus, 343.

Goldsmith, Mr., case, 168.

Gout, rheumatic, deformity from, 53,100.
Gowlland, case of burn-contracture, 200.
operation for dividing posterior tibial
tendon, 302.

Gradual contracture, 111.

Guerin’s views of rachitis, 203.
Gymnastics, 29, 382.

Glands, cervical, wry-neck from disease
of, 190.

Glisson, 236, 271.

Halpin, 192.

Hamilton, 196.

Hamstring tendons, mode of dividing,
82.

Hand contracted from paralysis, 120.
contracted from rheumatism, 100.
contracted from spasm, 109, 184.
contracted from burns, 187.
contracted from birth, 321, 334.
Hand, imperfect development of, 330.

malformation of, 330.

Hare, 383.

408

INDEX.

Harrison, 389.

Hip-disease, contraction, treatmentof, 69.
. lameness, diagnosis of, 66.
Hippocrates, acquaintance with club-foot,
3, 25.

on disease of the vertebrae, note, 34-8.
Hollis, case, 115.

Hoskins, Dr., case, 147.

Hypertrophy of fingers, 330.
of muscles, 14.
of toes, 331.

Hysterical contracture, 118, 137.
Hossard’s lever-belt, 390.

Idiocy and deformity, 187.

Imagination, influence of, in causing de¬
formity, 253.

Impaired nutrition, contraction from,
146.

In-knee, see Genu valgum.

Incomplete knee-ankylosis, 76.
Incurvation of spine, 352.

Infantile spastic rigidity, symptoms, 139.
Infants, management of diet, 204.
Inflammation, barrier to orthopaedic
treatment, 57.

cause of contracture after, 22, 52.
Intermitting contraction, 12, 186.
Instruments, mechanical, 30.

rules for applying, 38.

Intellect, sometimes feeble in deformity,
115.

Injunction, 29.

Irons in knock-knee, 216.

Inflammation of chest, danger of, in spinal
curvature, 349.

Inequality in length of legs, evils of, 112,
363.

Jackson, Mr., case, 166.

Jorg, 243.

Kennedy, Evory, Dr., 292.
Knee-ankylosis, 71.

ankylosis, division of tendons in, 82.
ankylosis, incomplete, 76.
ankylosis, mode of examining, 77.

Knee-ankylosis, morbid anatomy, 78.
ankylosis, treatment of angular, 79.
ankylosis, with displacement, 78.
ankylosis, value of tenotomy in, 87.
congenital luxations of, 319.
reduction of subluxatiou of, 85.
reduction of subluxation of, time re¬
quired for relief, 86.
Knee-apparatus, 80, 405.

Knock-knees. 208.

Kyllopodie, 308.

Labour, protracted, a cause of defor¬
mity, 116.

Lafond, 214.

Lallemand of Macclesfield, case, 199.
Langenbeck’s treatment of deformities
by violent extension, 240.

Lameness from ankle ankylosis, 91.
from hip-disease, 65.
congenital, 259.
paralytic, 150.
rickets and debility, 209.

Lateral curvature of spine, symptoms of,
365.

mode of origin, 368.
physiological, 368.
stages of, 374.
to left side (rare), 367.
treatment, 373, 387.

Lectures, why delivered, 1.

Lever, application of, 32.
in club-foot, 33.

Lever-belt, Hossard’s, incorrectly termed
Tavernier’s, 34, 390.

Ligaments, restoration of, 22.
shortening of, 132.

Little’s shoes for varus, 287, 292, 293.
Lob, 274.

Lonsdale’s statistics of deformities, 10.
Lordosis, 351.

Louvrier’s plan, and result of treatment,
60, 62.

Luxation, congenital, of hip, 316.
of knee, 319.

partial, of knee, with deformity, 75.
of shoulder, of wrist, 322.

INDEX.

Maisonnabe, 251.

M‘Intyre, Dr., case, 122.

Mackeever, 273.

Malformations, congenital, 324.
congenital, and distortion, interesting
case of, 334.

Malposition in utero, 256.

Manipulations, value of, 26.

with aid of chloroform, 42.

Massiter, division of, 176.

Maxillae, contracture of, 176.

mechanical separation of, 177.
Mechanical force, modes of applying, 31.
instruments, 30.

instruments, simplicity desirable in, 31.
Mellet, 37.

Michaelis, 4.

Minerva, the, 375.

Monstra deficientia et abundantia, 325.
Monstrosities, 326.

Morbid anatomy of club-foot, 271.
of contractures, 128.
of genu valgum, 211.
of spinal deformity, 342.
of talipes contracture, 133.

Mollities ossium, 227.

Muscle, atrophy of, 14.
hypertrophy of, 14.
restoration of, 22.

Muscular action, cause of all deformities,
338.

Mutter, Dr., 194.

Myotomy, subcutaneous, 45.
sub-conjunctival, 396.
submucous, 176.

Neglected cases, 397.

Nelson, 196.

Non-congenital deformities, 11.
talipes, 142.

talipes, mode of origin in childhood,
106, 145.

talipes, morbid anatomy of, 134.
talipes, spastic, 143.
talipes, varieties of, 144.
wry-neck, 188.
wry-neck, varieties, 189.

Open-air exercises necessary for preven¬
tion of deformity, 383.

Ordinary lateral curvature, 365.
Orthopaedic apparatus, simplicity desir¬
able, 37.

hospital, foundation of, 1.
hospitals, statistics of, 10, 225.
Orthopaedy, derivation of, 19.
means used in, 25.
nature of, 20.
objects of, 21.

why relinquished by former surgeons,

Outward curvature of entire extremity,
224.

Palletta, 24, 110, 274.

Palliative measures in deformities, 48.
Palmar fascia contracted, 179.

Paralysis, etiology of, 126.
congenital, 122, 316.
of anterior tibial, 152, 169.
of gastrocnemii, 159, 166.
not in proportion to deformity of spine,
note , 347.

Paralytic contractures, 120, 123, 149.
of knee, 110.
extent of, 121.
talipes equinus, 152.
valgus, 170.
varus, 154, 171.

deformity, sometimes congenital, 122.
deformity of spine, 360.

Partial ankylosis, 50, 52.

Parker, Dr., microscopic examination,
16.

Pathogeny of spasm and paralysis identi¬
cal, 126.

. Peronei tendons, division of, 93.

Plantar fascia, division of, 93.
Pigeon-breastedness, 214.

Pockels, 250.

Portal, note, 350.

Position, deformity from retention in
one, 11.

Posterior tibial, anatomy of, 298.

division of (Stromeyer’s method), 93.

410

INDEX.

Posterior tibial, division of (the author’s
plan), 297.

division of (Mr. Tamplin’s plan), 297.
different modes for dividing, 93, 296,
300.

Plantar fascia, disease of, 180.

Premature birth, contracture from, 114.

Preventive means in deformities, 48,383..

Pseudo-valgus, 230.

Pseudo-varus, see Paralytic Varus.

Rachitic curvature of spine (angular
and posterior), 350.
curvature of spine, treatment of, 351.
curvature of spine, state of bones, 352.
curvatures, mode of production, 222.
curvature with talipes, 229.
distortions, 202,219.
deformity of spine, 350, 351.
deformities, 204.
deformities, causes of, 205.
flattening of ribs, 214.

Rachitis, causes of, 203.
intimate nature of, 238.
opinions of older writers on: Glisson,

. Petit, Portal, Stanley, Duval, Gue¬
rin, Rokitansky, 236, 237.

Raphania, 146.

Re-adaptation of articular surfaces, 216.

Recumbency, 381, 388.

Relapsed cases, 397.

Repose in flat-foot, 235,

Retaining apparatus, 47, 399.

Rheumatism, deformities from, 53.
contracted hand from, 100.
contracted toes from, 94.
flat-foot from, 230.

Rickets, 24.

Rigidity, spastic, of new-born infants, 114.
from disease of brain in adult, 186.

Rokitansky, 227.

Round shoulders, 352.

Rudolphi, 243.

Ribs, deformity of, from rachitis, 214.
deformity of, from lateral curvature, 366.
deformity of, from angular curvature,
344.

Sandifort, 211.

Sartorius, 4.

Scarpa, 4, 24, 243.

shoe, modified by Stromeyer and Little,
287.

method of application, 289.
modified by Little, 292, 293.
Scaffoldings, 373.

Scoliosis, 365.

Screw, action of, 35.

in ankylosis, 34.

Shampooing, application of, 27.

Shaw, 208.

Shortening of ligaments, 132.

structural, of muscles, 13.

Shoulder, stiff, 97.

Situs mutatus, 327.

Simultaneous contractures, 110.

Sloughs, deformity from, 174.

from pressure, note, 35.

Spasm, etiology of, 125.

excited by act of willing, 186.
Spasmodic wry-neck, 119.

Spastic contraction, general, 113.
contraction of upper extremity, 148.
rigidity, analogues with, 118. ’

rigidity, general, 138.
rigidity, treatment of general, 140.
talipes, treatment of, 148.
talipes varus, 108.
wry-neck, 107.

Speech, difficulty of, with deformity, 114.
Spinal cord, disease of, from distortion,
106.

deformities, 339.
deformities, angular, 341.
deformities, lateral, 365.
deformities, posterior, 350.
deformities, apparent, 112.
deformities, congenital, 357.
deformities, paralytic, 360.
deformities, pleuritic, 361.
deformities, obscurity of study, 339.
deformities, pathology of, 340.
deformities, with hysteria, 19.
nerves, compression of, 128.
supports, utility of, 355.

INDEX.

411

Spinal-cord supports, worthlessness of
many, 36.

Splay-foot, see Flat-foot.

Springs, value of, 35.

Statistics of deformities, 10, 117, 225.

Sterno-mastoid, division of, 322.

Stiff fingers, 102.
ankle, treatment of, 91.
joint, 51.

joint, chloroformisation in, 60.
wrist, treatment of, 101.

Strabismus, 249, 394.

Stammering, 249.

Stromeyer, 5, 251, 343.
foot-board, 290.
foot-board, modified, 291.

Strephopodie, 308.

Structural shortening, 13.
shortening, clonic spasm incompatible
with much, 141.

Strumous disease and deformity of spine,
242.

Sub-conjunctival operation for Strabis¬
mus, 395.

Supernumerary parts, 331.

Suspension of trunk, 379.

Swedish exercises, 3851

Syme, 168.

Symmetry, alteration of, 16, 112.

Syndactylus, 326.

Talipes equinus, congenital, 259.
eqnino-varus, 106, 142.
equino-valgus, 169, 311.
calcaneus, 157.
calcaneus, progress of, 159.
calcaneo-valgus, 160, 312.
calcaneo-valgus, nature of, 124.
contracture, morbid anatomy of, 133.
non-congenital, 142.
varus, congenital, 261.
varus, grades of, 264.
varus, severe, operative treatment di¬
vided into two stages, 295.
valgus, congenital, 309.

Tamplin’s stilette and canula, 297.

Teeth, state of, in rachitis, 226.

Temperature, alteration of, 16, 122.
Tendo-Achillis, mode of dividing, 92.

position of, in T. varus, 108.

Tendon, operation for reunion of, 167.

division of, see Tenotomy.

Tenotomes, 301.

Tenotomy at elbow, 99.
at knee, 83.

censure of indiscriminate, 155.
in arm-contracture, 156.
in curvature, 228.

indications of, in congenital varus, 293.
stages in treatment, 295.

Tetanus-like contraction, 113.

Thilenius, 4.

Thilenian operation, 313.

Throat, contraction of muscles of, 114.
Tidy, Mr., case, 126.

Toes, deformed from improper shoes, 96.
deformed from rheumatism, 94.
supernumerary, 321.

Tourtual, 275.

Transient contraction, 12.

Treatment of angular knee ankylosis, 79.
of arm-contracture, 154.
of burn-contractures, 195.
of contractures, 136.
of curvatures of bones, 224, 226.
of general spastic rigidity, 140
of genu valgum, 212, 215.
of spastic talipes, 148.

Trismus nascentium, 138.

Trunk, elongation of, 378.

Umbilical cord, influence in producing
deformity, 256, 334.

Upper extremity, spastic contracture of,
148.

Universal paralytic contracture of the
lower extremities, 149.

Upper extremity, congenital distortion,
321.

Use, excessive, deformity from, 371.

Varus, congenital, 262.
non-congenital, 143.
splints for congenital, 286.

INDEX.

Varus (see also Talipes varus). Weakness of limbs, paralytic, 161.

Valgoid malformation of upper extremi- rachitic, 204.
ties, 331. Weight, 303.

Valgus, spurious, 231. Weis, 296.

non-congenital paralytic, 170. West, Dr., 161.

congenital, 310. Writer’s cramp, 184.

Velpeau, 296. paralysis, 185.

Vertebrae, caries and ankylosis of, Wrist, false ankylosis of, 102.

345. false ankylosis of, treatment, 102.

strumous disease, 342. paralytic contracture of, 120.

rachitic disease, 351. spastic contracture of, 148.

disease of, horizontal position in, Wry-neck, apparatus for, 193, 324.

347. congenital, 322.

disease of, terminations of, 348. diagnosis of various forms, 190.

deformity, of, secondary evils, 349. mechanical treatment, 193.

Violent treatment of deformities, evils of, non-congenital, 188; treatment, 192.
61. varieties, 189.

paralytic, treatment, 193.

Walther, von, 250. spastic, 107, 119.

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